Provider Demographics
NPI:1235711714
Name:MOORE, RHONDA LYNN (DTLLP)
Entity Type:Individual
Prefix:
First Name:RHONDA
Middle Name:LYNN
Last Name:MOORE
Suffix:
Gender:F
Credentials:DTLLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6409 STURBRIDGE DR
Mailing Address - Street 2:
Mailing Address - City:KALAMAZOO
Mailing Address - State:MI
Mailing Address - Zip Code:49004-9653
Mailing Address - Country:US
Mailing Address - Phone:269-615-5742
Mailing Address - Fax:
Practice Address - Street 1:1521 GULL RD
Practice Address - Street 2:
Practice Address - City:KALAMAZOO
Practice Address - State:MI
Practice Address - Zip Code:49048-1640
Practice Address - Country:US
Practice Address - Phone:269-226-8133
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-04-24
Last Update Date:2021-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6352000388103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist