MEDICARE: MICHE'L MOORE MS MFT

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	106H00000X	Marriage & Family Therapist	445-228	WI

General Provider Information

NPI Number	:	1508248402
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MICHE'L MOORE MS MFT

Provider Business Mailing Address
First Line	:	13309 WATERTOWN PLANK RD
Second Line	:
City	:	ELM GROVE
State	:	WI
Zip	:	53122-2217
Country	:	US
Telephone Number	:	262-649-3297
Fax Number	:

Provider Business Practice Location Address
First Line	:	13309 WATERTOWN PLANK RD
Second Line	:
City	:	ELM GROVE
State	:	WI
Zip	:	53122-2217
Country	:	US
Telephone Number	:	262-649-3297
Fax Number	:

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

Provider Enumeration Date	:	06/26/2015
Last Update Date	:	06/26/2015

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