Healthcare Provider Details

I. General information

NPI: 1275280281
Provider Name (Legal Business Name): TERESA BUROW MOORE LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/09/2022
Last Update Date: 06/15/2026
Certification Date: 06/15/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

110 N PERRY ST
PONTIAC MI
48342-2343
US

IV. Provider business mailing address

138 HIBBARD CT S
PONTIAC MI
48341-2172
US

V. Phone/Fax

Practice location:
  • Phone: 248-214-6678
  • Fax: 248-481-2074
Mailing address:
  • Phone: 646-941-7897
  • Fax: 929-596-7897

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number6401012598
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: