Provider Demographics
NPI:1154452910
Name:MOORE, KEVIN (MSW, LCSW)
Entity Type:Individual
Prefix:MR
First Name:KEVIN
Middle Name:
Last Name:MOORE
Suffix:
Gender:M
Credentials:MSW, LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 761
Mailing Address - Street 2:
Mailing Address - City:NORTH WEBSTER
Mailing Address - State:IN
Mailing Address - Zip Code:46555-0761
Mailing Address - Country:US
Mailing Address - Phone:574-535-0880
Mailing Address - Fax:574-535-0882
Practice Address - Street 1:313 S 3RD ST
Practice Address - Street 2:
Practice Address - City:GOSHEN
Practice Address - State:IN
Practice Address - Zip Code:46526-3709
Practice Address - Country:US
Practice Address - Phone:574-535-0880
Practice Address - Fax:574-535-0882
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-07
Last Update Date:2018-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN34005489A1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical