Provider Demographics
NPI:1386164275
Name:MOORE, DOMINIQUE MICHELLE
Entity type:Individual
Prefix:
First Name:DOMINIQUE
Middle Name:MICHELLE
Last Name:MOORE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:DOMINIQUE
Other - Middle Name:MICHELLE
Other - Last Name:ROBERSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:10112 SPENCER JONES RD
Mailing Address - Street 2:
Mailing Address - City:SPENCER
Mailing Address - State:OK
Mailing Address - Zip Code:73084-6900
Mailing Address - Country:US
Mailing Address - Phone:405-413-5809
Mailing Address - Fax:
Practice Address - Street 1:10326 GREENBRIAR PKWY
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73159-7643
Practice Address - Country:US
Practice Address - Phone:405-881-5057
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-06-22
Last Update Date:2017-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health