Provider Demographics
NPI:1073034369
Name:MOORE, MADGELL (LCSW)
Entity Type:Individual
Prefix:
First Name:MADGELL
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 1:3131 ROSALIND LOOP
Mailing Address - Street 2:
Mailing Address - City:ANCHORAGE
Mailing Address - State:AK
Mailing Address - Zip Code:99507-3674
Mailing Address - Country:US
Mailing Address - Phone:907-360-0403
Mailing Address - Fax:
Practice Address - Street 1:2600 DENALI ST STE 606
Practice Address - Street 2:
Practice Address - City:ANCHORAGE
Practice Address - State:AK
Practice Address - Zip Code:99503-2754
Practice Address - Country:US
Practice Address - Phone:907-343-9207
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-06-28
Last Update Date:2017-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK1202031041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical