Provider Demographics
NPI:1407447410
Name:MIGHTY-MOORE, DONNA-LEE
Entity Type:Individual
Prefix:
First Name:DONNA-LEE
Middle Name:
Last Name:MIGHTY-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 1:4877 TRIGER LN
Mailing Address - Street 2:
Mailing Address - City:FAIRBURN
Mailing Address - State:GA
Mailing Address - Zip Code:30213-2087
Mailing Address - Country:US
Mailing Address - Phone:678-789-6999
Mailing Address - Fax:
Practice Address - Street 1:500 LANIER AVE W STE 508
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30214-7637
Practice Address - Country:US
Practice Address - Phone:678-489-7384
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-02-02
Last Update Date:2021-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor