Provider Demographics
NPI:1497910079
Name:MOORE, DONALD R (LLMSW CAAC)
Entity Type:Individual
Prefix:MR
First Name:DONALD
Middle Name:R
Last Name:MOORE
Suffix:
Gender:M
Credentials:LLMSW CAAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3393 OAKMAN BLVD
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48238-4200
Mailing Address - Country:US
Mailing Address - Phone:313-875-5521
Mailing Address - Fax:
Practice Address - Street 1:5470 CHENE ST
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48211-2746
Practice Address - Country:US
Practice Address - Phone:313-875-5521
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-23
Last Update Date:2010-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health