Healthcare Provider Details

I. General information

NPI: 1720349368
Provider Name (Legal Business Name): MARTINA S MOORE MA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/30/2012
Last Update Date: 12/15/2022
Certification Date: 12/15/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

22639 EUCLID AVE
EUCLID OH
44117-1622
US

IV. Provider business mailing address

22639 EUCLID AVE
EUCLID OH
44117-1622
US

V. Phone/Fax

Practice location:
  • Phone: 216-404-1900
  • Fax: 216-404-1901
Mailing address:
  • Phone: 216-404-1900
  • Fax: 216-404-1901

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number975996
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberE.1700264-SUPV
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: