Healthcare Provider Details

I. General information

NPI: 1841776697
Provider Name (Legal Business Name): PATIENCE MOORE, LCSW, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/16/2018
Last Update Date: 07/12/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

460 BLOOMFIELD AVE STE 306
MONTCLAIR NJ
07042-3552
US

IV. Provider business mailing address

460 BLOOMFIELD AVE STE 306
MONTCLAIR NJ
07042-3552
US

V. Phone/Fax

Practice location:
  • Phone: 973-907-4755
  • Fax:
Mailing address:
  • Phone: 973-907-4755
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number44SC05641900
License Number StateNJ
# 2
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number44SC05641900
License Number StateNJ
# 3
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number44SC05411900
License Number StateNJ

VIII. Authorized Official

Name: MS. PATIENCE MOORE
Title or Position: FOUNDER
Credential: LCSW
Phone: 973-907-4755