Provider Demographics
NPI:1982182259
Name:MOORE, MARSHALL (LMSW)
Entity Type:Individual
Prefix:
First Name:MARSHALL
Middle Name:
Last Name:MOORE
Suffix:
Gender:M
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5524 ARAPAHO PASS
Mailing Address - Street 2:
Mailing Address - City:PINCKNEY
Mailing Address - State:MI
Mailing Address - Zip Code:48169-8729
Mailing Address - Country:US
Mailing Address - Phone:810-623-0372
Mailing Address - Fax:
Practice Address - Street 1:17 W MAIN ST # 1
Practice Address - Street 2:
Practice Address - City:MILAN
Practice Address - State:MI
Practice Address - Zip Code:48160-1213
Practice Address - Country:US
Practice Address - Phone:734-627-7650
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-07-30
Last Update Date:2020-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68011005931041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical