Healthcare Provider Details

I. General information

NPI: 1992520563
Provider Name (Legal Business Name): GERTRUDE OLIVIA MOORE LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/19/2024
Last Update Date: 09/02/2026
Certification Date: 09/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

922 HIGHWAY 81 E STE 438
MCDONOUGH GA
30252-2978
US

IV. Provider business mailing address

922 HIGHWAY 81 E STE 438
MCDONOUGH GA
30252-2978
US

V. Phone/Fax

Practice location:
  • Phone: 850-420-8479
  • Fax:
Mailing address:
  • Phone: 850-420-8479
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberSW27185
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: