Provider Demographics
NPI:1073718623
Name:PATRICK M. MOORE, ACSW, LCSW, PC
Entity Type:Organization
Organization Name:PATRICK M. MOORE, ACSW, LCSW, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ACCOUNTS MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:TAMMY
Authorized Official - Middle Name:
Authorized Official - Last Name:LAMPKE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:765-288-7939
Mailing Address - Street 1:1945 W ROYALE DR
Mailing Address - Street 2:
Mailing Address - City:MUNCIE
Mailing Address - State:IN
Mailing Address - Zip Code:47304-2265
Mailing Address - Country:US
Mailing Address - Phone:765-288-7939
Mailing Address - Fax:765-288-7841
Practice Address - Street 1:1945 W ROYALE DR
Practice Address - Street 2:
Practice Address - City:MUNCIE
Practice Address - State:IN
Practice Address - Zip Code:47304-2265
Practice Address - Country:US
Practice Address - Phone:765-288-7939
Practice Address - Fax:765-288-7841
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-15
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN34001741A101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN216970AMedicare ID - Type Unspecified