Provider Demographics
NPI:1659606705
Name:MICHELLE MOORE, PHD, LLC
Entity Type:Organization
Organization Name:MICHELLE MOORE, PHD, LLC
Other - Org Name:MOORE BEHAVIORAL HEALTH
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CLINICAL PSYCHOLOGIST
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHELLE
Authorized Official - Middle Name:RENEE
Authorized Official - Last Name:WIDOWS
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:303-345-3728
Mailing Address - Street 1:1710 BEARBERRY CIR APT 101
Mailing Address - Street 2:
Mailing Address - City:LUTZ
Mailing Address - State:FL
Mailing Address - Zip Code:33559-8781
Mailing Address - Country:US
Mailing Address - Phone:303-345-3728
Mailing Address - Fax:888-868-5424
Practice Address - Street 1:1710 BEARBERRY CIR APT 101
Practice Address - Street 2:
Practice Address - City:LUTZ
Practice Address - State:FL
Practice Address - Zip Code:33559-8781
Practice Address - Country:US
Practice Address - Phone:303-345-3728
Practice Address - Fax:888-868-5424
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-10-07
Last Update Date:2012-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO3155103T00000X, 103TC0700X, 103TH0004X
FLPY6699103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Multi-Specialty
No103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Multi-Specialty
No103TH0004XBehavioral Health & Social Service ProvidersPsychologistHealthGroup - Multi-Specialty