Provider Demographics
NPI:1790433498
Name:MOORE, BREANNA J (LMSW)
Entity Type:Individual
Prefix:
First Name:BREANNA
Middle Name:J
Last Name:MOORE
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:BREANNA
Other - Middle Name:J
Other - Last Name:SHEA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:109 PARK ST
Mailing Address - Street 2:
Mailing Address - City:TECUMSEH
Mailing Address - State:MI
Mailing Address - Zip Code:49286-1229
Mailing Address - Country:US
Mailing Address - Phone:517-902-4726
Mailing Address - Fax:
Practice Address - Street 1:140 W MIDDLE ST
Practice Address - Street 2:
Practice Address - City:CHELSEA
Practice Address - State:MI
Practice Address - Zip Code:48118-1293
Practice Address - Country:US
Practice Address - Phone:517-902-4726
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-03-13
Last Update Date:2022-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68511026591041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical