Provider Demographics
NPI:1295071132
Name:MOORE, DONNA LYNN (LLBSW)
Entity type:Individual
Prefix:MS
First Name:DONNA
Middle Name:LYNN
Last Name:MOORE
Suffix:
Gender:F
Credentials:LLBSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9409 WEST PICKWICK CICLE
Mailing Address - Street 2:
Mailing Address - City:TAYLOR
Mailing Address - State:MI
Mailing Address - Zip Code:48180
Mailing Address - Country:US
Mailing Address - Phone:313-854-8013
Mailing Address - Fax:
Practice Address - Street 1:9409 W PICKWICK CIR
Practice Address - Street 2:
Practice Address - City:TAYLOR
Practice Address - State:MI
Practice Address - Zip Code:48180-3860
Practice Address - Country:US
Practice Address - Phone:313-854-8013
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-12-21
Last Update Date:2012-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6802086890104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker