Provider Demographics
NPI:1346572740
Name:MOORE, KATHLEEN A (MS, LLPC)
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:A
Last Name:MOORE
Suffix:
Gender:F
Credentials:MS, LLPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1221 W LAKETON AVE
Mailing Address - Street 2:
Mailing Address - City:MUSKEGON
Mailing Address - State:MI
Mailing Address - Zip Code:49441-2866
Mailing Address - Country:US
Mailing Address - Phone:231-759-7909
Mailing Address - Fax:231-759-8618
Practice Address - Street 1:1221 W LAKETON AVE
Practice Address - Street 2:
Practice Address - City:MUSKEGON
Practice Address - State:MI
Practice Address - Zip Code:49441-2866
Practice Address - Country:US
Practice Address - Phone:231-759-7909
Practice Address - Fax:231-759-8618
Is Sole Proprietor?:Yes
Enumeration Date:2010-02-10
Last Update Date:2010-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6401011331101YP2500X, 101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101Y00000XBehavioral Health & Social Service ProvidersCounselor