Healthcare Provider Details

I. General information

NPI: 1427062165
Provider Name (Legal Business Name): DEREK DYKES MOORE LICSW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/28/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

22 MCGRATH HWY
SOMERVILLE MA
02143-4508
US

IV. Provider business mailing address

10 BRIDGE ST
MARBLEHEAD MA
01945-3711
US

V. Phone/Fax

Practice location:
  • Phone: 617-623-1814
  • Fax: 617-623-1817
Mailing address:
  • Phone: 617-893-2231
  • Fax: 617-623-1817

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number113305
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: