Provider Demographics
NPI:1710330097
Name:MOORE, DIANA T (BA)
Entity Type:Individual
Prefix:
First Name:DIANA
Middle Name:T
Last Name:MOORE
Suffix:
Gender:F
Credentials:BA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:G3500 FLUSHING RD STE 250
Mailing Address - Street 2:
Mailing Address - City:FLINT
Mailing Address - State:MI
Mailing Address - Zip Code:48504-4238
Mailing Address - Country:US
Mailing Address - Phone:810-249-9924
Mailing Address - Fax:810-249-9927
Practice Address - Street 1:G3500 FLUSHING RD STE 250
Practice Address - Street 2:
Practice Address - City:FLINT
Practice Address - State:MI
Practice Address - Zip Code:48504-4238
Practice Address - Country:US
Practice Address - Phone:810-249-9924
Practice Address - Fax:810-249-9927
Is Sole Proprietor?:No
Enumeration Date:2016-07-21
Last Update Date:2016-07-21
Deactivation Date:
Deactivation Code:
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Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)