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NPI Code Detail

MEDICARE: MR. DEREK DYKES MOORE LICSW

MEDICARE: MR. DEREK DYKES MOORE LICSW
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
11041C0700XClinical Social Worker113305MA

General Provider Information

NPI Number : 1427062165
Entity Type Code : Individual
Provider Name (Legal Business Name) : MR. DEREK DYKES MOORE LICSW
Provider Business Mailing Address
First Line : 10 BRIDGE ST
Second Line :
City : MARBLEHEAD
State : MA
Zip : 01945-3711
Country : US
Telephone Number : 617-893-2231
Fax Number : 617-623-1817
Provider Business Practice Location Address
First Line : 22 MCGRATH HWY
Second Line :
City : SOMERVILLE
State : MA
Zip : 02143-4508
Country : US
Telephone Number : 617-623-1814
Fax Number : 617-623-1817
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 07/28/2006
Last Update Date : 07/08/2007

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Directions to “ MR. DEREK DYKES MOORE LICSW” Practice Location

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