Healthcare Provider Details

I. General information

NPI: 1013392596
Provider Name (Legal Business Name): KERIE MOORE LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/24/2015
Last Update Date: 07/31/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

406 E VINE ST
VIENNA IL
62995-1612
US

IV. Provider business mailing address

408 E VINE ST PO BOX 1328
VIENNA IL
62995-1612
US

V. Phone/Fax

Practice location:
  • Phone: 618-658-3079
  • Fax:
Mailing address:
  • Phone: 618-658-2611
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number149021412
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: