Provider Demographics
NPI:1043458516
Name:MOORE, GENNEA NICKOLE (LLP)
Entity Type:Individual
Prefix:MS
First Name:GENNEA
Middle Name:NICKOLE
Last Name:MOORE
Suffix:
Gender:F
Credentials:LLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22524 SCHROEDER AVE
Mailing Address - Street 2:
Mailing Address - City:EASTPOINTE
Mailing Address - State:MI
Mailing Address - Zip Code:48021-4010
Mailing Address - Country:US
Mailing Address - Phone:248-469-9519
Mailing Address - Fax:
Practice Address - Street 1:18303 E 10 MILE RD
Practice Address - Street 2:
Practice Address - City:ROSEVILLE
Practice Address - State:MI
Practice Address - Zip Code:48066-4988
Practice Address - Country:US
Practice Address - Phone:248-469-9519
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-01-21
Last Update Date:2022-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301013299103T00000X, 103TC0700X
MI6351000450103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical