Provider Demographics
NPI:1992156673
Name:MOORE, BROOKE (LLMSW)
Entity type:Individual
Prefix:
First Name:BROOKE
Middle Name:
Last Name:MOORE
Suffix:
Gender:F
Credentials:LLMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:538 VENETIAN CT
Mailing Address - Street 2:
Mailing Address - City:BAY CITY
Mailing Address - State:MI
Mailing Address - Zip Code:48708-6965
Mailing Address - Country:US
Mailing Address - Phone:989-948-4446
Mailing Address - Fax:
Practice Address - Street 1:3175 PROFESSIONAL CT
Practice Address - Street 2:
Practice Address - City:BAY CITY
Practice Address - State:MI
Practice Address - Zip Code:48706-2823
Practice Address - Country:US
Practice Address - Phone:989-667-3377
Practice Address - Fax:989-667-9991
Is Sole Proprietor?:No
Enumeration Date:2016-06-23
Last Update Date:2021-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6801104918104100000X
247200000X
MI6851104918104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No247200000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, Other