MEDICARE: MRS. GLORIST DYAN MOORE LCSW

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	1041C0700X	Clinical Social Worker	44SC05286700	NJ

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1265641153
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. GLORIST DYAN MOORE LCSW

Provider Business Mailing Address
First Line	:	437 ZION RD
Second Line	:
City	:	EGG HARBOR TOWNSHIP
State	:	NJ
Zip	:	08234-6904
Country	:	US
Telephone Number	:	609-926-6981
Fax Number	:	606-926-6981

Provider Business Practice Location Address
First Line	:	437 ZION RD
Second Line	:
City	:	EGG HARBOR TOWNSHIP
State	:	NJ
Zip	:	08234-6904
Country	:	US
Telephone Number	:	609-926-6981
Fax Number	:	606-926-6981

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

Provider Enumeration Date	:	05/21/2007
Last Update Date	:	07/08/2007

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