Provider Demographics
NPI:1295962413
Name:MOORE, LISA JEANINE (LMSW)
Entity type:Individual
Prefix:MRS
First Name:LISA
Middle Name:JEANINE
Last Name:MOORE
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:MS
Other - First Name:LISA
Other - Middle Name:JEANINE
Other - Last Name:THORNTON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LMSW
Mailing Address - Street 1:22511 TELEGRAPH RD
Mailing Address - Street 2:SUITE 101
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48033-4115
Mailing Address - Country:US
Mailing Address - Phone:248-356-0540
Mailing Address - Fax:
Practice Address - Street 1:22511 TELEGRAPH RD
Practice Address - Street 2:SUITE 101
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48033-4115
Practice Address - Country:US
Practice Address - Phone:248-356-0540
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-06-15
Last Update Date:2009-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010787721041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical