Healthcare Provider Details

I. General information

NPI: 1518022458
Provider Name (Legal Business Name): PATRICK MICHAEL MOORE ACSW, LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/22/2006
Last Update Date: 03/27/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1700 E 38TH ST
MARION IN
46953-4568
US

IV. Provider business mailing address

1700 E 38TH ST
MARION IN
46953-4568
US

V. Phone/Fax

Practice location:
  • Phone: 765-674-3321
  • Fax: 765-677-5115
Mailing address:
  • Phone: 765-674-3321
  • Fax: 765-677-5115

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number34001741
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: