=====================================================
General NPI Number Information
=====================================================
NPI Number | 1871900373
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JOHN MOORE MS
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/16/2014
-----------------------------------------------------
Last Update Date | 12/04/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1800 N MILFORD RD STE 100
-----------------------------------------------------
City | MILFORD
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48381-1047
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 810-222-9847
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1800 N MILFORD RD STE 100
-----------------------------------------------------
City | MILFORD
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48381-1047
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 248-684-6400
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103T00000X
-----------------------------------------------------
Taxonomy Name | Psychologist
-----------------------------------------------------
License Number | 6301011549
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 103TC2200X
-----------------------------------------------------
Taxonomy Name | Clinical Child & Adolescent Psychologist
-----------------------------------------------------
License Number | 6361004249
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 103K00000X
-----------------------------------------------------
Taxonomy Name | Behavior Analyst
-----------------------------------------------------
License Number | 7401000465
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------