Provider Demographics
NPI:1316620065
Name:MOOREHEAD, AMY KAYLYN
Entity type:Individual
Prefix:
First Name:AMY
Middle Name:KAYLYN
Last Name:MOOREHEAD
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 1:26210 HARPER AVE STE 200
Mailing Address - Street 2:
Mailing Address - City:SAINT CLAIR SHORES
Mailing Address - State:MI
Mailing Address - Zip Code:48081-2203
Mailing Address - Country:US
Mailing Address - Phone:888-485-8636
Mailing Address - Fax:
Practice Address - Street 1:26210 HARPER AVE STE 200
Practice Address - Street 2:
Practice Address - City:SAINT CLAIR SHORES
Practice Address - State:MI
Practice Address - Zip Code:48081-2203
Practice Address - Country:US
Practice Address - Phone:775-387-3004
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-08-09
Last Update Date:2024-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVRBT3626106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician