Healthcare Provider Details

I. General information

NPI: 1265390041
Provider Name (Legal Business Name): MS. TALISA RENEE MOORE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/12/2026
Last Update Date: 08/23/2026
Certification Date: 08/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

23800 W 10 MILE RD STE 105
SOUTHFIELD MI
48033-3199
US

IV. Provider business mailing address

220 W CONGRESS ST FL 2
DETROIT MI
48226-3289
US

V. Phone/Fax

Practice location:
  • Phone: 248-450-6500
  • Fax:
Mailing address:
  • Phone: 313-217-6404
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: