Provider Demographics
NPI:1295863496
Name:MOORE, NOLAN KEITH (LPC)
Entity Type:Individual
Prefix:MR
First Name:NOLAN
Middle Name:KEITH
Last Name:MOORE
Suffix:
Gender:M
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20510 KENTFIELD ST
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48219-1446
Mailing Address - Country:US
Mailing Address - Phone:313-570-0832
Mailing Address - Fax:313-822-2664
Practice Address - Street 1:20510 KENTFIELD ST
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48219-1446
Practice Address - Country:US
Practice Address - Phone:313-570-0832
Practice Address - Fax:313-822-2664
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6401003213101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional