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General NPI Number Information
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NPI Number | 1629442231
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Entity Type | Individual
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Provider Name | SEAN SMITH-MOORE LCSW
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Gender | Male
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Dates
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Enumeration Date | 11/19/2015
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Last Update Date | 04/22/2021
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Provider Practice Location Address
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Address Line | 4309 N KENMORE AVE UNIT 2
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City | CHICAGO
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State | IL
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Zip | 60613-7352
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Country | US
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Telephone | 301-974-5985
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Fax |
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Provider Business Mailing Address
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Address Line | 5068 N WINCHESTER AVE APT 3N
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City | CHICAGO
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State | IL
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Zip | 60640-7896
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Country | US
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Telephone |
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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 | 101YA0400X
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Taxonomy Name | Addiction (Substance Use Disorder) Counselor
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License Number | 34978
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License Number State | IL
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Taxonomy #2
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Taxonomy Code | 104100000X
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Taxonomy Name | Social Worker
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License Number | LG50081367
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License Number State | DC
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Taxonomy #3
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Taxonomy Code | 104100000X
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Taxonomy Name | Social Worker
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License Number | 20792
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License Number State | MD
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Taxonomy #4
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number | 149019678
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License Number State | IL
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