Healthcare Provider Details

I. General information

NPI: 1902536584
Provider Name (Legal Business Name): KIMBERLY MOORER
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/15/2022
Last Update Date: 06/15/2022
Certification Date: 06/15/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

805 N 6TH ST
SHEBOYGAN WI
53081-4113
US

IV. Provider business mailing address

1031 MARYLAND AVE UNIT 230
SHEBOYGAN WI
53081-4911
US

V. Phone/Fax

Practice location:
  • Phone: 920-457-8866
  • Fax:
Mailing address:
  • Phone: 414-263-8281
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number226-4535
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: