Provider Demographics
NPI:1629566864
Name:MOORE, CORIANDRE DAEVON (MA LPCC)
Entity Type:Individual
Prefix:
First Name:CORIANDRE
Middle Name:DAEVON
Last Name:MOORE
Suffix:
Gender:M
Credentials:MA LPCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3333 BURNET AVE. ML 2023
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45229-3026
Mailing Address - Country:US
Mailing Address - Phone:513-636-4371
Mailing Address - Fax:513-636-7657
Practice Address - Street 1:3333 BURNET AVE
Practice Address - Street 2:
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45229-3026
Practice Address - Country:US
Practice Address - Phone:513-636-4371
Practice Address - Fax:513-636-7657
Is Sole Proprietor?:No
Enumeration Date:2018-04-24
Last Update Date:2023-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHC.1500066101YM0800X
OHE.1901205101YP2500X, 101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional