Provider Demographics
NPI:1073031019
Name:MOORE, MARK DANIEL (MA SCHOOL PSYCHOLOGY)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:DANIEL
Last Name:MOORE
Suffix:
Gender:M
Credentials:MA SCHOOL PSYCHOLOGY
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 MINER ST
Mailing Address - Street 2:
Mailing Address - City:CRESCENT CITY
Mailing Address - State:IL
Mailing Address - Zip Code:60928-8092
Mailing Address - Country:US
Mailing Address - Phone:815-683-2662
Mailing Address - Fax:
Practice Address - Street 1:100 MINER ST
Practice Address - Street 2:
Practice Address - City:CRESCENT CITY
Practice Address - State:IL
Practice Address - Zip Code:60928-8092
Practice Address - Country:US
Practice Address - Phone:815-683-2662
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-08-30
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1986210103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL$$$$$$$$$Medicaid