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General NPI Number Information
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NPI Number | 1528490877
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Entity Type | Individual
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Provider Name | DERIK MOORE
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Gender | Male
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Dates
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Enumeration Date | 08/08/2013
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Last Update Date | 09/02/2024
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Provider Practice Location Address
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Address Line | 230 S BROAD ST STE 1903
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City | PHILADELPHIA
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State | PA
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Zip | 19102-4121
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Country | US
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Telephone | 267-258-1027
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Fax |
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Provider Business Mailing Address
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Address Line | 451 ROXBOROUGH AVE
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City | PHILADELPHIA
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State | PA
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Zip | 19128-3536
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Country | US
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Telephone | 267-258-1027
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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 | 44SC05928700
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License Number State | NJ
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Taxonomy #2
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number | CW018657
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License Number State | PA
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