MEDICARE: DR. KATHLEEN MCGUIRE-MOORE PH.D.

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	103TC0700X	Clinical Psychologist	6301005835	MI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	680-F3-3047	OTHER	MI	BCBS PIN

General Provider Information

NPI Number	:	1427188754
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. KATHLEEN MCGUIRE-MOORE PH.D.

Provider Business Mailing Address
First Line	:	817 LOCKWOOD RD
Second Line	:
City	:	ROYAL OAK
State	:	MI
Zip	:	48067-1609
Country	:	US
Telephone Number	:	248-546-8914
Fax Number	:	248-269-6047

Provider Business Practice Location Address
First Line	:	755 W BIG BEAVER RD
Second Line	:
City	:	TROY
State	:	MI
Zip	:	48084-4900
Country	:	US
Telephone Number	:	248-546-8914
Fax Number	:	248-269-6047

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

Provider Enumeration Date	:	03/06/2007
Last Update Date	:	07/08/2007

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