MEDICARE: MR. NOLAN KEITH MOORE LPC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YP2500X	Professional Counselor	6401003213	MI

General Provider Information

NPI Number	:	1295863496
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. NOLAN KEITH MOORE LPC

Provider Business Mailing Address
First Line	:	20510 KENTFIELD ST
Second Line	:
City	:	DETROIT
State	:	MI
Zip	:	48219-1446
Country	:	US
Telephone Number	:	313-570-0832
Fax Number	:	313-822-2664

Provider Business Practice Location Address
First Line	:	20510 KENTFIELD ST
Second Line	:
City	:	DETROIT
State	:	MI
Zip	:	48219-1446
Country	:	US
Telephone Number	:	313-570-0832
Fax Number	:	313-822-2664

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/01/2007
Last Update Date	:	07/08/2007

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