Provider Demographics
NPI:1275346363
Name:MOORE, MICHELLE
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:
Last Name:MOORE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15526 JEWEL AVE APT 3C
Mailing Address - Street 2:
Mailing Address - City:FLUSHING
Mailing Address - State:NY
Mailing Address - Zip Code:11367-1861
Mailing Address - Country:US
Mailing Address - Phone:443-220-9008
Mailing Address - Fax:
Practice Address - Street 1:107 W 82ND ST # LLP101
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10024-5511
Practice Address - Country:US
Practice Address - Phone:646-389-4112
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-01-31
Last Update Date:2025-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst