Healthcare Provider Details

I. General information

NPI: 1952047714
Provider Name (Legal Business Name): CYNTHIA R MOORE APSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/05/2022
Last Update Date: 05/05/2022
Certification Date: 05/05/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5930 SEMINOLE CENTRE CT STE C
FITCHBURG WI
53711-5165
US

IV. Provider business mailing address

6400 INDUSTRIAL LOOP
GREENDALE WI
53129-2452
US

V. Phone/Fax

Practice location:
  • Phone: 608-630-8889
  • Fax: 608-200-7268
Mailing address:
  • Phone: 414-858-4106
  • Fax: 414-423-4134

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number13207-121
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: