Healthcare Provider Details

I. General information

NPI: 1144983198
Provider Name (Legal Business Name): DOMINIQUE EUNICE MOORE LLC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/18/2021
Last Update Date: 08/05/2025
Certification Date: 08/05/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8150 OLD 13 MILE RD
WARREN MI
48093-8700
US

IV. Provider business mailing address

26545 AMERICAN DR
SOUTHFIELD MI
48034-6115
US

V. Phone/Fax

Practice location:
  • Phone: 800-395-3223
  • Fax:
Mailing address:
  • Phone: 800-395-3223
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number6451024307
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: