Healthcare Provider Details

I. General information

NPI: 1265183115
Provider Name (Legal Business Name): MIRA LUNA FUENTES MOORE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/12/2022
Last Update Date: 01/12/2022
Certification Date: 01/12/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1874 4TH ST
WYANDOTTE MI
48192-3905
US

IV. Provider business mailing address

PO BOX 265
WYANDOTTE MI
48192-0265
US

V. Phone/Fax

Practice location:
  • Phone: 734-828-9599
  • Fax:
Mailing address:
  • Phone: 734-828-9599
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TA0700X
TaxonomyAdult Development & Aging Psychologist
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: