Provider Demographics
NPI:1265713895
Name:MOORE, MICHELLE BEATRICE (LSW)
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:BEATRICE
Last Name:MOORE
Suffix:
Gender:F
Credentials:LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17 NEW SOUTH ST
Mailing Address - Street 2:SUITE 116
Mailing Address - City:NORTHAMPTON
Mailing Address - State:MA
Mailing Address - Zip Code:01060-4073
Mailing Address - Country:US
Mailing Address - Phone:413-582-0471
Mailing Address - Fax:413-582-1807
Practice Address - Street 1:17 NEW SOUTH ST
Practice Address - Street 2:SUITE 116
Practice Address - City:NORTHAMPTON
Practice Address - State:MA
Practice Address - Zip Code:01060-4073
Practice Address - Country:US
Practice Address - Phone:413-582-0471
Practice Address - Fax:413-582-1807
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-09
Last Update Date:2011-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA313749251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health