Healthcare Provider Details

I. General information

NPI: 1295910685
Provider Name (Legal Business Name): SANDI MOORE LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/03/2008
Last Update Date: 07/27/2026
Certification Date: 07/27/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

609 E WASHINGTON ST
IDABEL OK
74745-3319
US

IV. Provider business mailing address

511 SE MADISON ST
IDABEL OK
74745-4926
US

V. Phone/Fax

Practice location:
  • Phone: 580-217-7962
  • Fax:
Mailing address:
  • Phone: 580-612-2112
  • Fax: 580-297-9163

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number4145
License Number StateOK
# 2
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number3530
License Number StateOK
# 3
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: