Provider Demographics
NPI:1487005393
Name:MOORE, JUSTIN ANTHONY
Entity type:Individual
Prefix:
First Name:JUSTIN
Middle Name:ANTHONY
Last Name:MOORE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1189 WILMETTE AVE STE 263
Mailing Address - Street 2:
Mailing Address - City:WILMETTE
Mailing Address - State:IL
Mailing Address - Zip Code:60091-2719
Mailing Address - Country:US
Mailing Address - Phone:224-216-4443
Mailing Address - Fax:
Practice Address - Street 1:400 CENTRAL AVE STE 220
Practice Address - Street 2:
Practice Address - City:NORTHFIELD
Practice Address - State:IL
Practice Address - Zip Code:60093-3024
Practice Address - Country:US
Practice Address - Phone:847-996-9994
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-06-22
Last Update Date:2023-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3606-57103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist