Healthcare Provider Details

I. General information

NPI: 1881264406
Provider Name (Legal Business Name): MAYA RENE MOORE LICSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/27/2021
Last Update Date: 07/12/2023
Certification Date: 07/12/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1710 ALLEN ST
KELSO WA
98626-4907
US

IV. Provider business mailing address

PO BOX 34703
SEATTLE WA
98124-1703
US

V. Phone/Fax

Practice location:
  • Phone: 360-261-7020
  • Fax:
Mailing address:
  • Phone: 206-764-0502
  • Fax: 206-764-0516

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLW61368575
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: