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General NPI Number Information
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NPI Number | 1447368162
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Entity Type | Individual
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Provider Name | ELIZABETH C IRWIN MOORE LCSW
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Gender | Female
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Dates
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Enumeration Date | 08/25/2006
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Last Update Date | 09/12/2007
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Provider Practice Location Address
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Address Line | 1220 DEWEY AVE BLDG #3
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City | WAUWATOSA
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State | WI
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Zip | 53213
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Country | US
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Telephone | 414-454-6566
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Fax | 414-454-6522
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Provider Business Mailing Address
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Address Line | 1220 DEWEY AVE
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City | WAUWATOSA
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State | WI
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Zip | 53213-2504
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Country | US
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Telephone | 414-454-6779
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number | 6763-123
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License Number State | WI
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