=====================================================
General NPI Number Information
=====================================================
NPI Number | 1669864179
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JUDY MOORE LMSW
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/21/2015
-----------------------------------------------------
Last Update Date | 02/21/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3000 E 112TH AVE UNIT 70
-----------------------------------------------------
City | NORTHGLENN
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 80233-4685
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 303-319-2207
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3000 E 112TH AVE UNIT 70
-----------------------------------------------------
City | NORTHGLENN
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 80233-4685
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 303-319-2207
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | LMSW 9398
-----------------------------------------------------
License Number State | KS
-----------------------------------------------------