Provider Demographics
NPI:1194519207
Name:MOORE, MICHAEL LEMUEL SR (BA, MS)
Entity type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:LEMUEL
Last Name:MOORE
Suffix:SR
Gender:
Credentials:BA, MS
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:
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:925-450-8182
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-04-05
Last Update Date:2025-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171400000X
CA101YP1600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP1600XBehavioral Health & Social Service ProvidersCounselorPastoral
No171400000XOther Service ProvidersHealth & Wellness Coach