| Doctor Name: | MS. GENNEA NICKOLE MOORE |
| NPI Number: | 1043458516 |
| Entity Type Code: | Individual (1) |
| Gender: | F |
| Credentials: | LLP |
| License Number: | 6301013299 |
| Business Practice Address: | 22708 Harper Ave Saint Clair Shores, MI - 480801823 |
| Business Phone Number: | 5862643692 |
| Business Fax Number: | |
| Mailing Address: | 21023 Poinciana St, SOUTHFIELD |
| State: | MI |
| Postal Code: | 480335041 |
| Phone Number: | 2487961014 |
| Fax Number: | 2488092088 |
| NPI Enumeration Date: | 01/21/2009 |
| NPI Last Update Date: | 05/17/2013 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 103TC0700X |
| License Number: | 6301013299 |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | MI |
| Taxonomy Type: | Behavioral Health & Social Service Providers |
| Taxonomy Classification: | Psychologist |
| Taxonomy Specialization: | Clinical |
| Taxonomy Definition: | |