Provider Demographics
NPI:1154468015
Name:MOORERESIDENCE HOME, INC
Entity Type:Organization
Organization Name:MOORERESIDENCE HOME, INC
Other - Org Name:MOORE RESIDENCE HOME, INC. MULTI PURPOSE CENTER
Other - Org Type:Other Name
Authorized Official - Title/Position:FOUNDER PRESIDENT
Authorized Official - Prefix:MS
Authorized Official - First Name:DONNA
Authorized Official - Middle Name:A
Authorized Official - Last Name:MOORE
Authorized Official - Suffix:
Authorized Official - Credentials:MHS, LMHC
Authorized Official - Phone:718-739-7420
Mailing Address - Street 1:P.O. BOX 650 439
Mailing Address - Street 2:
Mailing Address - City:FRESH MEADOWS
Mailing Address - State:NY
Mailing Address - Zip Code:11365
Mailing Address - Country:US
Mailing Address - Phone:718-739-7420
Mailing Address - Fax:718-487-3722
Practice Address - Street 1:16305 107TH AVE
Practice Address - Street 2:SUITE 1R
Practice Address - City:JAMAICA
Practice Address - State:NY
Practice Address - Zip Code:11433-2101
Practice Address - Country:US
Practice Address - Phone:718-739-7420
Practice Address - Fax:718-487-3722
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-31
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY10889101YA0400X
NY003801-1101YM0800X
NY209905-1164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Single Specialty
Not Answered101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty
Not Answered164W00000XNursing Service ProvidersLicensed Practical NurseGroup - Single Specialty