Healthcare Provider Details

I. General information

NPI: 1699249045
Provider Name (Legal Business Name): SCOTT MOORE
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/18/2019
Last Update Date: 04/11/2023
Certification Date: 04/11/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

506 6TH ST
RAPID CITY SD
57701-2726
US

IV. Provider business mailing address

506 6TH ST
RAPID CITY SD
57701-2726
US

V. Phone/Fax

Practice location:
  • Phone: 314-375-6208
  • Fax:
Mailing address:
  • Phone: 314-375-6208
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number2022047477
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number6312
License Number StateSD

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: