=====================================================
General NPI Number Information
=====================================================
NPI Number | 1538779863
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MOORE THERAPEUTIC AND CONSULTING SERVICES
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/02/2020
-----------------------------------------------------
Last Update Date | 08/02/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1600 MARYLAND AVE NE APT 257
-----------------------------------------------------
City | WASHINGTON
-----------------------------------------------------
State | DC
-----------------------------------------------------
Zip | 20002-7662
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 571-247-8039
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1600 MARYLAND AVE NE APT 257
-----------------------------------------------------
City | WASHINGTON
-----------------------------------------------------
State | DC
-----------------------------------------------------
Zip | 20002-7662
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 571-247-8039
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CLINICAL SOCIAL WORKER
-----------------------------------------------------
Name | MS. TYRA MOORE
-----------------------------------------------------
Credential | LICSW, LCSW-C
-----------------------------------------------------
Telephone | 571-247-8039
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------