Healthcare Provider Details

I. General information

NPI: 1891478590
Provider Name (Legal Business Name): MARIAH ELIZABETH MOORE LSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/09/2023
Last Update Date: 07/14/2026
Certification Date: 07/14/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2148 EAGLE PASS STE H
WOOSTER OH
44691-5357
US

IV. Provider business mailing address

2148 EAGLE PASS STE H
WOOSTER OH
44691-5357
US

V. Phone/Fax

Practice location:
  • Phone: 330-345-8970
  • Fax:
Mailing address:
  • Phone: 330-345-8970
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberS.2512172
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: