Provider Demographics
NPI:1154332609
Name:MOORE, JOHN PATRICK (LICSW)
Entity Type:Individual
Prefix:MR
First Name:JOHN
Middle Name:PATRICK
Last Name:MOORE
Suffix:
Gender:M
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8385 113TH ST S
Mailing Address - Street 2:
Mailing Address - City:COTTAGE GROVE
Mailing Address - State:MN
Mailing Address - Zip Code:55016-4520
Mailing Address - Country:US
Mailing Address - Phone:651-458-8647
Mailing Address - Fax:
Practice Address - Street 1:ONE VETERANS DRIVE
Practice Address - Street 2:VA MEDICAL CENTER (116A2/3)
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55417
Practice Address - Country:US
Practice Address - Phone:612-467-4783
Practice Address - Fax:612-467-5309
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN132251041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical