Healthcare Provider Details

I. General information

NPI: 1184124638
Provider Name (Legal Business Name): SHIRLEE BUCHANAN MOORE JR. DTLLP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/20/2018
Last Update Date: 01/20/2021
Certification Date: 01/20/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5985 W MAIN ST STE 101
KALAMAZOO MI
49009-8708
US

IV. Provider business mailing address

16782 VON KARMAN AVE STE 11
IRVINE CA
92606-2417
US

V. Phone/Fax

Practice location:
  • Phone: 269-459-1818
  • Fax:
Mailing address:
  • Phone: 855-223-7123
  • Fax: 619-374-7134

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License Number6352000466
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: