Provider Demographics
NPI:1083248249
Name:MOSES, PHILLIP DUJUAN (LLMSW)
Entity Type:Individual
Prefix:
First Name:PHILLIP
Middle Name:DUJUAN
Last Name:MOSES
Suffix:
Gender:M
Credentials:LLMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:516 E 12 MILE RD
Mailing Address - Street 2:
Mailing Address - City:ROYAL OAK
Mailing Address - State:MI
Mailing Address - Zip Code:48073-4123
Mailing Address - Country:US
Mailing Address - Phone:313-454-9915
Mailing Address - Fax:
Practice Address - Street 1:5640 W MAPLE RD
Practice Address - Street 2:
Practice Address - City:WEST BLOOMFIELD
Practice Address - State:MI
Practice Address - Zip Code:48322-3716
Practice Address - Country:US
Practice Address - Phone:313-454-9915
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-02-26
Last Update Date:2020-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6801105217104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes104100000XBehavioral Health & Social Service ProvidersSocial WorkerGroup - Multi-Specialty