Provider Demographics
NPI:1184124638
Name:MOORE, SHIRLEE BUCHANAN JR (DTLLP)
Entity type:Individual
Prefix:
First Name:SHIRLEE
Middle Name:BUCHANAN
Last Name:MOORE
Suffix:JR
Gender:F
Credentials:DTLLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16782 VON KARMAN AVE STE 11
Mailing Address - Street 2:
Mailing Address - City:IRVINE
Mailing Address - State:CA
Mailing Address - Zip Code:92606-2417
Mailing Address - Country:US
Mailing Address - Phone:855-223-7123
Mailing Address - Fax:619-374-7134
Practice Address - Street 1:5985 W MAIN ST STE 101
Practice Address - Street 2:
Practice Address - City:KALAMAZOO
Practice Address - State:MI
Practice Address - Zip Code:49009-8708
Practice Address - Country:US
Practice Address - Phone:269-459-1818
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-02-20
Last Update Date:2021-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA106S00000X
MI6352000466103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician