Provider Demographics
NPI:1063669190
Name:MOORE, LORRAINE COLLETTE (BSW)
Entity Type:Individual
Prefix:MS
First Name:LORRAINE
Middle Name:COLLETTE
Last Name:MOORE
Suffix:
Gender:F
Credentials:BSW
Other - Prefix:MRS
Other - First Name:LORRAINE
Other - Middle Name:COLLETTE
Other - Last Name:MOORE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:1151 TAYLOR ST
Mailing Address - Street 2:BLDG 6, ROOM 139
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48202-1732
Mailing Address - Country:US
Mailing Address - Phone:313-876-4008
Mailing Address - Fax:313-876-0523
Practice Address - Street 1:1151 TAYLOR ST
Practice Address - Street 2:ROOM 332-C
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48202-1732
Practice Address - Country:US
Practice Address - Phone:313-876-0360
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-08-20
Last Update Date:2008-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6802069860104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker