Provider Demographics
NPI:1154635076
Name:MOORE, JOHN MICHEAL (LCSW)
Entity Type:Individual
Prefix:MR
First Name:JOHN
Middle Name:MICHEAL
Last Name:MOORE
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15 BAYVIEW AVE
Mailing Address - Street 2:
Mailing Address - City:EAST ISLIP
Mailing Address - State:NY
Mailing Address - Zip Code:11730-2401
Mailing Address - Country:US
Mailing Address - Phone:631-581-2542
Mailing Address - Fax:
Practice Address - Street 1:15 BAYVIEW AVE
Practice Address - Street 2:
Practice Address - City:EAST ISLIP
Practice Address - State:NY
Practice Address - Zip Code:11730-2401
Practice Address - Country:US
Practice Address - Phone:631-581-2542
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-08-03
Last Update Date:2010-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYR042827-11041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical