Provider Demographics
NPI:1760683049
Name:MOORE, MARY (MA)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:MOORE
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2115 BROADWAY AVE
Mailing Address - Street 2:
Mailing Address - City:KALAMAZOO
Mailing Address - State:MI
Mailing Address - Zip Code:49008-1614
Mailing Address - Country:US
Mailing Address - Phone:269-344-4413
Mailing Address - Fax:
Practice Address - Street 1:200 TURWILL LN
Practice Address - Street 2:
Practice Address - City:KALAMAZOO
Practice Address - State:MI
Practice Address - Zip Code:49006-4277
Practice Address - Country:US
Practice Address - Phone:269-344-4413
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301007034103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist