Healthcare Provider Details

I. General information

NPI: 1982977336
Provider Name (Legal Business Name): DEVON MICHELLE MOORE MSW, LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/15/2012
Last Update Date: 02/15/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1530 S 18TH ST
LAFAYETTE IN
47905-2010
US

IV. Provider business mailing address

1530 S 18TH ST
LAFAYETTE IN
47905-2010
US

V. Phone/Fax

Practice location:
  • Phone: 765-418-6850
  • Fax: 765-477-7806
Mailing address:
  • Phone: 765-418-6850
  • Fax: 765-477-7806

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number33005691A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: