Provider Demographics
NPI:1699542522
Name:MOORE, CASSIDY OLIVIA
Entity type:Individual
Prefix:
First Name:CASSIDY
Middle Name:OLIVIA
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 1:4444 8-MILE RD
Mailing Address - Street 2:2711 E OUTER DR, DETROIT MI 48234
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48234
Mailing Address - Country:US
Mailing Address - Phone:313-628-2028
Mailing Address - Fax:
Practice Address - Street 1:4444 8-MILE RD
Practice Address - Street 2:2711 OUTER DRIVE EAST
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48234
Practice Address - Country:US
Practice Address - Phone:313-628-2028
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-12-11
Last Update Date:2023-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker