Healthcare Provider Details

I. General information

NPI: 1841438561
Provider Name (Legal Business Name): LILA MOORE LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/03/2009
Last Update Date: 05/08/2025
Certification Date: 05/08/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1174 PRINCES CIR
SYRACUSE UT
84075-6830
US

IV. Provider business mailing address

1174 PRINCES CIR
SYRACUSE UT
84075-6830
US

V. Phone/Fax

Practice location:
  • Phone: 918-209-8138
  • Fax:
Mailing address:
  • Phone: 918-209-8138
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number55396
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number5585
License Number StateOK
# 3
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number13642618-3501
License Number StateUT

VII. Legacy identifiers

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

# 1
Identifier55396
Identifier TypeOTHER
Identifier StateTX
Identifier IssuerLICENSE
# 2
Identifier41630
Identifier TypeOTHER
Identifier StateID
Identifier IssuerLCSW
# 3
Identifier13642618-3501
Identifier TypeOTHER
Identifier StateUT
Identifier IssuerLCSW
# 4
Identifier5585
Identifier TypeOTHER
Identifier StateOK
Identifier IssuerISSUER

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: