Provider Demographics
NPI:1629945944
Name:MOORE, LAURA
Entity type:Individual
Prefix:MRS
First Name:LAURA
Middle Name:
Last Name:MOORE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:COACH
Other - Middle Name:
Other - Last Name:MOORE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:29488 WOODWARD AVE # 507
Mailing Address - Street 2:
Mailing Address - City:ROYAL OAK
Mailing Address - State:MI
Mailing Address - Zip Code:48073-0903
Mailing Address - Country:US
Mailing Address - Phone:248-571-7040
Mailing Address - Fax:313-217-3246
Practice Address - Street 1:29488 WOODWARD AVE # 507
Practice Address - Street 2:
Practice Address - City:ROYAL OAK
Practice Address - State:MI
Practice Address - Zip Code:48073-0903
Practice Address - Country:US
Practice Address - Phone:248-571-7040
Practice Address - Fax:313-217-3246
Is Sole Proprietor?:No
Enumeration Date:2025-10-21
Last Update Date:2025-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI101YA0400X, 101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)