Provider Demographics
NPI:1144216771
Name:MOORE, MAGGIE (LISW)
Entity Type:Individual
Prefix:
First Name:MAGGIE
Middle Name:
Last Name:MOORE
Suffix:
Gender:F
Credentials:LISW
Other - Prefix:
Other - First Name:BETTY
Other - Middle Name:MARGUERITE
Other - Last Name:MOORE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LISW
Mailing Address - Street 1:200 HAWKINS DR
Mailing Address - Street 2:
Mailing Address - City:IOWA CITY
Mailing Address - State:IA
Mailing Address - Zip Code:52242-1009
Mailing Address - Country:US
Mailing Address - Phone:319-353-6366
Mailing Address - Fax:319-384-8843
Practice Address - Street 1:200 HAWKINS DR
Practice Address - Street 2:
Practice Address - City:IOWA CITY
Practice Address - State:IA
Practice Address - Zip Code:52242-1009
Practice Address - Country:US
Practice Address - Phone:319-353-6366
Practice Address - Fax:319-384-8843
Is Sole Proprietor?:No
Enumeration Date:2005-09-20
Last Update Date:2007-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA00849104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA26576OtherWELLMARK BCBS
P27611Medicare UPIN
IAI1627Medicare PIN