Provider Demographics
NPI:1235825571
Name:MOORE, NONA
Entity Type:Individual
Prefix:
First Name:NONA
Middle Name:
Last Name:MOORE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:23830 SARAVILLA DR APT 6
Mailing Address - Street 2:
Mailing Address - City:CLINTON TOWNSHIP
Mailing Address - State:MI
Mailing Address - Zip Code:48035-3174
Mailing Address - Country:US
Mailing Address - Phone:313-773-4625
Mailing Address - Fax:
Practice Address - Street 1:27085 GRATIOT AVE STE 107
Practice Address - Street 2:
Practice Address - City:ROSEVILLE
Practice Address - State:MI
Practice Address - Zip Code:48066-2984
Practice Address - Country:US
Practice Address - Phone:586-285-5361
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-04-11
Last Update Date:2023-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health