Provider Demographics
NPI:1467216341
Name:MOORE, ANDRE JEMAR
Entity Type:Individual
Prefix:
First Name:ANDRE
Middle Name:JEMAR
Last Name:MOORE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3786 NORTHWOOD RD
Mailing Address - Street 2:
Mailing Address - City:UNIVERSITY HT
Mailing Address - State:OH
Mailing Address - Zip Code:44118-3738
Mailing Address - Country:US
Mailing Address - Phone:216-971-0164
Mailing Address - Fax:
Practice Address - Street 1:5162 BROADWAY AVE
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44127-1571
Practice Address - Country:US
Practice Address - Phone:216-938-6829
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-02-12
Last Update Date:2024-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty