Healthcare Provider Details

I. General information

NPI: 1659730166
Provider Name (Legal Business Name): KRISTIN MOORE MSW, LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/12/2016
Last Update Date: 02/12/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2140 UPPER WETUMPKA RD
MONTGOMERY AL
36107-1342
US

IV. Provider business mailing address

67 BROOKFIELD DR
ELMORE AL
36025-1243
US

V. Phone/Fax

Practice location:
  • Phone: 334-279-7830
  • Fax:
Mailing address:
  • Phone: 334-462-8817
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number3717C
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: