MEDICARE: MARK DANIEL MOORE MA SCHOOL PSYCHOLOGY

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103TS0200X	School Psychologist	1986210	IL

General Provider Information

NPI Number	:	1073031019
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARK DANIEL MOORE MA SCHOOL PSYCHOLOGY

Provider Business Mailing Address
First Line	:	100 MINER ST
Second Line	:
City	:	CRESCENT CITY
State	:	IL
Zip	:	60928-8092
Country	:	US
Telephone Number	:	815-683-2662
Fax Number	:

Provider Business Practice Location Address
First Line	:	100 MINER ST
Second Line	:
City	:	CRESCENT CITY
State	:	IL
Zip	:	60928-8092
Country	:	US
Telephone Number	:	815-683-2662
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/30/2017
Last Update Date	:	07/21/2022

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