Provider Demographics
NPI:1114231602
Name:MOORE, AMY LYNN (LPC)
Entity Type:Individual
Prefix:MS
First Name:AMY
Middle Name:LYNN
Last Name:MOORE
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3182 JONATHAN RD
Mailing Address - Street 2:
Mailing Address - City:OXFORD
Mailing Address - State:MI
Mailing Address - Zip Code:48371-1250
Mailing Address - Country:US
Mailing Address - Phone:248-924-4722
Mailing Address - Fax:
Practice Address - Street 1:1120 S LAPEER RD
Practice Address - Street 2:
Practice Address - City:OXFORD
Practice Address - State:MI
Practice Address - Zip Code:48371-6180
Practice Address - Country:US
Practice Address - Phone:248-924-4722
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-07-27
Last Update Date:2014-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MH6401007804101YP2500X
101YS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YS0200XBehavioral Health & Social Service ProvidersCounselorSchool