Healthcare Provider Details

I. General information

NPI: 1306591433
Provider Name (Legal Business Name): BONNIE HARRIS-MOORE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/17/2022
Last Update Date: 02/09/2023
Certification Date: 02/09/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12265 JAMES ST
HOLLAND MI
49424-8613
US

IV. Provider business mailing address

12265 JAMES ST
HOLLAND MI
49424-8613
US

V. Phone/Fax

Practice location:
  • Phone: 161-639-3568
  • Fax:
Mailing address:
  • Phone: 616-393-5685
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: