Healthcare Provider Details

I. General information

NPI: 1093368565
Provider Name (Legal Business Name): AMBER MOORE LSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/23/2019
Last Update Date: 12/16/2025
Certification Date: 12/16/2025
Deactivation Date: 03/12/2020
Reactivation Date: 04/09/2020

III. Provider practice location address

204 COOK RD
LEBANON OH
45036-9600
US

IV. Provider business mailing address

2600 VICTORY PKWY
CINCINNATI OH
45206-1395
US

V. Phone/Fax

Practice location:
  • Phone: 513-751-7747
  • Fax:
Mailing address:
  • Phone: 513-751-7747
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberS.2512643
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: