Healthcare Provider Details

I. General information

NPI: 1245517895
Provider Name (Legal Business Name): GEORGE J MOORE LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/10/2011
Last Update Date: 09/03/2026
Certification Date: 09/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

930 S FORTUNA BLVD
FORTUNA CA
95540-3009
US

IV. Provider business mailing address

PO BOX 769
REDWAY CA
95560-0769
US

V. Phone/Fax

Practice location:
  • Phone: 707-923-2783
  • Fax:
Mailing address:
  • Phone: 707-923-2783
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number082400
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number080335
License Number StateNY
# 3
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number93051
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: