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General NPI Number Information
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NPI Number | 1760649628
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Entity Type | Individual
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Provider Name | MICHELLE GLYNISE MOORE EARLY INTERVENTION P
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Gender | Female
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Dates
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Enumeration Date | 05/19/2008
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Last Update Date | 07/15/2025
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Provider Practice Location Address
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Address Line | PO BOX 658
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City | BLUE ISLAND
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State | IL
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Zip | 60406
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Country | US
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Telephone | 708-698-0714
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Fax |
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Provider Business Mailing Address
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Address Line | 246 E JANATA BLVD STE 111
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City | LOMBARD
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State | IL
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Zip | 60148-5317
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Country | US
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Telephone | 708-698-0714
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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 | 104100000X
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Taxonomy Name | Social Worker
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License Number | 150107720
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License Number State | IL
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Taxonomy #2
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number | 149027689
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License Number State | IL
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Taxonomy #3
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Taxonomy Code | 252Y00000X
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Taxonomy Name | Early Intervention Provider Agency
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License Number |
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License Number State | IL
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