Provider Demographics
NPI:1417638040
Name:MOORE, EMMA JEAN
Entity Type:Individual
Prefix:
First Name:EMMA
Middle Name:JEAN
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 1:614 ROMENCE RD
Mailing Address - Street 2:
Mailing Address - City:PORTAGE
Mailing Address - State:MI
Mailing Address - Zip Code:49024-3613
Mailing Address - Country:US
Mailing Address - Phone:269-615-7637
Mailing Address - Fax:
Practice Address - Street 1:4341 S WESTNEDGE AVE STE 1203
Practice Address - Street 2:
Practice Address - City:KALAMAZOO
Practice Address - State:MI
Practice Address - Zip Code:49008-3284
Practice Address - Country:US
Practice Address - Phone:269-615-7637
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-07-27
Last Update Date:2023-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68511169121041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical