Provider Demographics
NPI:1063630622
Name:MOORE, CONSTANCE B (LCSW)
Entity Type:Individual
Prefix:
First Name:CONSTANCE
Middle Name:B
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 1:6143 HUNTER WOODS LN
Mailing Address - Street 2:
Mailing Address - City:TALLAHASSEE
Mailing Address - State:FL
Mailing Address - Zip Code:32311-9004
Mailing Address - Country:US
Mailing Address - Phone:850-524-5048
Mailing Address - Fax:
Practice Address - Street 1:2365 CENTERVILLE RD STE 11
Practice Address - Street 2:
Practice Address - City:TALLAHASSEE
Practice Address - State:FL
Practice Address - Zip Code:32308-4317
Practice Address - Country:US
Practice Address - Phone:850-425-5025
Practice Address - Fax:850-425-5026
Is Sole Proprietor?:No
Enumeration Date:2007-04-20
Last Update Date:2019-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSW53211041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLZ0300Medicare ID - Type Unspecified