Provider Demographics
NPI:1174259287
Name:MOORE, NYDRA (LLMSW)
Entity Type:Individual
Prefix:
First Name:NYDRA
Middle Name:
Last Name:MOORE
Suffix:
Gender:F
Credentials:LLMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3362 PARKLAND AVE SW
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49509-3467
Mailing Address - Country:US
Mailing Address - Phone:616-329-9857
Mailing Address - Fax:
Practice Address - Street 1:2010 KALAMAZOO AVE SE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49507-4004
Practice Address - Country:US
Practice Address - Phone:616-329-9857
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-07-29
Last Update Date:2022-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker