Provider Demographics
NPI:1790959575
Name:MOORE, BRENEE' D (LMSW)
Entity Type:Individual
Prefix:
First Name:BRENEE'
Middle Name:D
Last Name:MOORE
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:259 E CHICAGO ST
Mailing Address - Street 2:
Mailing Address - City:COLDWATER
Mailing Address - State:MI
Mailing Address - Zip Code:49036-2046
Mailing Address - Country:US
Mailing Address - Phone:517-320-5657
Mailing Address - Fax:517-278-8901
Practice Address - Street 1:259 E CHICAGO ST
Practice Address - Street 2:
Practice Address - City:COLDWATER
Practice Address - State:MI
Practice Address - Zip Code:49036-2046
Practice Address - Country:US
Practice Address - Phone:517-320-5657
Practice Address - Fax:517-278-8901
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-14
Last Update Date:2014-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010860221041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIMI2588001Medicare PIN