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General NPI Number Information
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NPI Number | 1154468015
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Entity Type | Organization
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Legal Business Name | MOORERESIDENCE HOME, INC
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Dates
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Enumeration Date | 01/31/2007
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Last Update Date | 09/11/2025
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Provider Practice Location Address
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Address Line | 16305 107TH AVE SUITE 1R
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City | JAMAICA
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State | NY
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Zip | 11433-2101
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Country | US
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Telephone | 718-739-7420
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Fax | 718-487-3722
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Provider Business Mailing Address
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Address Line | P.O. BOX 650 439
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City | FRESH MEADOWS
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State | NY
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Zip | 11365
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Country | US
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Telephone | 718-739-7420
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Fax | 718-487-3722
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Authorized Official
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Title or Position | FOUNDER PRESIDENT
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Name | MS. DONNA A MOORE
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Credential | MHS, LMHC
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Telephone | 718-739-7420
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YA0400X
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Taxonomy Name | Addiction (Substance Use Disorder) Counselor
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License Number | 10889
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License Number State | NY
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Taxonomy #2
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Taxonomy Code | 164W00000X
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Taxonomy Name | Licensed Practical Nurse
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License Number | 209905-1
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License Number State | NY
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Taxonomy #3
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Taxonomy Code | 101YM0800X
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Taxonomy Name | Mental Health Counselor
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License Number | 003801-1
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License Number State | NY
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