Healthcare Provider Details

I. General information

NPI: 1912567215
Provider Name (Legal Business Name): KATRINA ROSE MOORE MSW, LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/18/2019
Last Update Date: 12/12/2025
Certification Date: 12/12/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3324 MILWAUKEE ST
MADISON WI
53714-1866
US

IV. Provider business mailing address

17 HARDING ST
MADISON WI
53714-2218
US

V. Phone/Fax

Practice location:
  • Phone: 608-843-4604
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number131530121
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: