Healthcare Provider Details

I. General information

NPI: 1922376102
Provider Name (Legal Business Name): EILEEN G MOORE LSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/02/2011
Last Update Date: 12/02/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

735 WILSON ST
BREWER ME
04412-1000
US

IV. Provider business mailing address

PO BOX 1599
BANGOR ME
04402-1599
US

V. Phone/Fax

Practice location:
  • Phone: 207-989-1567
  • Fax: 207-989-2287
Mailing address:
  • Phone: 207-945-5247
  • Fax: 207-947-0435

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberLS4281
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: