Provider Demographics
NPI:1114915022
Name:MOORE, HOWARD E (PHD)
Entity Type:Individual
Prefix:DR
First Name:HOWARD
Middle Name:E
Last Name:MOORE
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:28175 HAGGERTY RD
Mailing Address - Street 2:
Mailing Address - City:NOVI
Mailing Address - State:MI
Mailing Address - Zip Code:48377-2903
Mailing Address - Country:US
Mailing Address - Phone:248-994-1154
Mailing Address - Fax:
Practice Address - Street 1:28175 HAGGERTY RD
Practice Address - Street 2:
Practice Address - City:NOVI
Practice Address - State:MI
Practice Address - Zip Code:48377-2903
Practice Address - Country:US
Practice Address - Phone:248-994-1154
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-13
Last Update Date:2021-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301003046103T00000X, 103TC0700X, 103TC0700X
MI4101005233106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103T00000XBehavioral Health & Social Service ProvidersPsychologist
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI038864OtherVALUE OPTIONS
MI11284079OtherCAQH
MI8672000OtherMAGELLAN BEHAVIORIAL ID
MI680F347290OtherBLUE CROSS PIN
MI11284079OtherCAQH
MI8672000OtherMAGELLAN BEHAVIORIAL ID