Provider Demographics
NPI:1447745948
Name:MOORE, DIAMOND
Entity Type:Individual
Prefix:
First Name:DIAMOND
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 1:1735 S HAWKINS AVE
Mailing Address - Street 2:
Mailing Address - City:AKRON
Mailing Address - State:OH
Mailing Address - Zip Code:44320-3902
Mailing Address - Country:US
Mailing Address - Phone:330-867-5400
Mailing Address - Fax:333-869-8263
Practice Address - Street 1:1735 S HAWKINS AVE
Practice Address - Street 2:
Practice Address - City:AKRON
Practice Address - State:OH
Practice Address - Zip Code:44320-3902
Practice Address - Country:US
Practice Address - Phone:330-867-5400
Practice Address - Fax:333-869-8263
Is Sole Proprietor?:Yes
Enumeration Date:2018-06-27
Last Update Date:2019-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171M00000X
OH161700405300000X
OH168055101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
No405300000XOther Service ProvidersPrevention Professional