Healthcare Provider Details

I. General information

NPI: 1629566864
Provider Name (Legal Business Name): CORIANDRE DAEVON MOORE MA LPCC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/24/2018
Last Update Date: 04/18/2023
Certification Date: 04/12/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3333 BURNET AVE
CINCINNATI OH
45229-3026
US

IV. Provider business mailing address

3333 BURNET AVE. ML 2023
CINCINNATI OH
45229-3026
US

V. Phone/Fax

Practice location:
  • Phone: 513-636-4371
  • Fax: 513-636-7657
Mailing address:
  • Phone: 513-636-4371
  • Fax: 513-636-7657

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License NumberE.1901205
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberC.1500066
License Number StateOH
# 3
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberE.1901205
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: