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General NPI Number Information
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NPI Number | 1144829037
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Entity Type | Individual
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Provider Name | DAMON MOORE
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Gender | Male
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Dates
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Enumeration Date | 10/21/2020
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Last Update Date | 10/21/2020
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Provider Practice Location Address
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Address Line | 15450 E JEFFERSON AVE STE 180
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City | GROSSE POINTE PARK
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State | MI
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Zip | 48230-2031
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Country | US
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Telephone | 313-444-4393
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Fax |
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Provider Business Mailing Address
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Address Line | 25898 CHIPPENDALE CT APT A
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City | ROSEVILLE
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State | MI
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Zip | 48066-3975
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Country | US
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Telephone | 810-937-9137
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103TS0200X
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Taxonomy Name | School Psychologist
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License Number | PP0000001037037
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License Number State | MI
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Taxonomy #2
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Taxonomy Code | 103T00000X
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Taxonomy Name | Psychologist
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License Number | 6362009236
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License Number State | MI
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