Healthcare Provider Details

I. General information

NPI: 1659665750
Provider Name (Legal Business Name): TAMMY LYNN MOORE LISW-S
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/06/2011
Last Update Date: 01/05/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2700 E MAIN ST SUITE 102
BEXLEY OH
43209-2536
US

IV. Provider business mailing address

1200 W 5TH AVE SUITE 102-D
COLUMBUS OH
43212-2503
US

V. Phone/Fax

Practice location:
  • Phone: 614-398-1180
  • Fax:
Mailing address:
  • Phone: 614-398-1180
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberI0700225-S
License Number StateOH

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: