Provider Demographics
NPI:1801019989
Name:MOORE, VERNON (MSW)
Entity Type:Individual
Prefix:MR
First Name:VERNON
Middle Name:
Last Name:MOORE
Suffix:
Gender:M
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16527 CRUSE ST
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48235-4004
Mailing Address - Country:US
Mailing Address - Phone:313-341-1130
Mailing Address - Fax:313-341-1130
Practice Address - Street 1:16527 CRUSE ST
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48235-4004
Practice Address - Country:US
Practice Address - Phone:313-341-1130
Practice Address - Fax:313-341-1130
Is Sole Proprietor?:No
Enumeration Date:2007-04-10
Last Update Date:2014-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI6801073651OtherMSW