Provider Demographics
NPI:1780020388
Name:MOORE, ROBERT R
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:R
Last Name:MOORE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:88 BECKWITH DR
Mailing Address - Street 2:
Mailing Address - City:GALESBURG
Mailing Address - State:MI
Mailing Address - Zip Code:49053-9604
Mailing Address - Country:US
Mailing Address - Phone:269-317-4954
Mailing Address - Fax:
Practice Address - Street 1:88 BECKWITH DR
Practice Address - Street 2:
Practice Address - City:GALESBURG
Practice Address - State:MI
Practice Address - Zip Code:49053-9604
Practice Address - Country:US
Practice Address - Phone:269-317-4954
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-05-22
Last Update Date:2013-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor