MEDICARE: MRS. SUSAN ELIZABETH STEVENSON MOORE MSW LCSW

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
1	1041C0700X	Clinical Social Worker	006256	MO

General Provider Information

NPI Number	:	1831172436
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. SUSAN ELIZABETH STEVENSON MOORE MSW LCSW

Provider Business Mailing Address
First Line	:	745 CRAIG RD STE 104
Second Line	:
City	:	CREVE COEUR
State	:	MO
Zip	:	63141-7122
Country	:	US
Telephone Number	:	314-606-1265
Fax Number	:	314-202-6016

Provider Business Practice Location Address
First Line	:	745 CRAIG RD STE 104
Second Line	:
City	:	CREVE COEUR
State	:	MO
Zip	:	63141-7122
Country	:	US
Telephone Number	:	314-606-1265
Fax Number	:	314-202-6016

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/29/2005
Last Update Date	:	05/11/2020

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