Healthcare Provider Details

I. General information

NPI: 1942086087
Provider Name (Legal Business Name): TERRENCE PATRICK MOORE LMSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/05/2023
Last Update Date: 06/06/2024
Certification Date: 06/06/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4500 BLACK ROCK RD STE 103
HAMPSTEAD MD
21074-2649
US

IV. Provider business mailing address

13817 SADDLEVIEW DR
NORTH POTOMAC MD
20878-3853
US

V. Phone/Fax

Practice location:
  • Phone: 877-806-1501
  • Fax:
Mailing address:
  • Phone: 240-477-3022
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number31606
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: