Provider Demographics
NPI:1356884852
Name:MOORE, MICHAEL LEMUEL II
Entity type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:LEMUEL
Last Name:MOORE
Suffix:II
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:665 ROTUNDA WAY
Mailing Address - Street 2:
Mailing Address - City:BRENTWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:94513-5534
Mailing Address - Country:US
Mailing Address - Phone:510-502-1667
Mailing Address - Fax:
Practice Address - Street 1:665 ROTUNDA WAY
Practice Address - Street 2:
Practice Address - City:BRENTWOOD
Practice Address - State:CA
Practice Address - Zip Code:94513-5534
Practice Address - Country:US
Practice Address - Phone:510-502-1667
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-12-01
Last Update Date:2017-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
No171M00000XOther Service ProvidersCase Manager/Care Coordinator