Provider Demographics
NPI:1578798542
Name:MOORE, ELISE R (MA, LLP)
Entity Type:Individual
Prefix:
First Name:ELISE
Middle Name:R
Last Name:MOORE
Suffix:
Gender:F
Credentials:MA, LLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18185 WILSON DR
Mailing Address - Street 2:
Mailing Address - City:BIG RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49307-9729
Mailing Address - Country:US
Mailing Address - Phone:231-408-2358
Mailing Address - Fax:
Practice Address - Street 1:128 N WARREN AVE STE B
Practice Address - Street 2:
Practice Address - City:BIG RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49307-3207
Practice Address - Country:US
Practice Address - Phone:164-580-6926
Practice Address - Fax:616-458-8129
Is Sole Proprietor?:Yes
Enumeration Date:2009-05-20
Last Update Date:2022-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301011828103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist