Provider Demographics
NPI:1013392596
Name:MOORE, KERIE (LCSW)
Entity Type:Individual
Prefix:
First Name:KERIE
Middle Name:
Last Name:MOORE
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:408 E VINE ST
Mailing Address - Street 2:PO BOX 1328
Mailing Address - City:VIENNA
Mailing Address - State:IL
Mailing Address - Zip Code:62995-1612
Mailing Address - Country:US
Mailing Address - Phone:618-658-2611
Mailing Address - Fax:
Practice Address - Street 1:406 E VINE ST
Practice Address - Street 2:
Practice Address - City:VIENNA
Practice Address - State:IL
Practice Address - Zip Code:62995-1612
Practice Address - Country:US
Practice Address - Phone:618-658-3079
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-07-24
Last Update Date:2019-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1490214121041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical