Provider Demographics
NPI:1720349368
Name:MOORE, MARTINA S (MA)
Entity Type:Individual
Prefix:MRS
First Name:MARTINA
Middle Name:S
Last Name:MOORE
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22639 EUCLID AVE
Mailing Address - Street 2:
Mailing Address - City:EUCLID
Mailing Address - State:OH
Mailing Address - Zip Code:44117-1622
Mailing Address - Country:US
Mailing Address - Phone:216-404-1900
Mailing Address - Fax:216-404-1901
Practice Address - Street 1:22639 EUCLID AVE
Practice Address - Street 2:
Practice Address - City:EUCLID
Practice Address - State:OH
Practice Address - Zip Code:44117-1622
Practice Address - Country:US
Practice Address - Phone:216-404-1900
Practice Address - Fax:216-404-1901
Is Sole Proprietor?:Yes
Enumeration Date:2012-05-30
Last Update Date:2022-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH975996101YA0400X
OHE.1700264-SUPV101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)