Provider Demographics
NPI:1174033559
Name:MOORE, ZACHARY (LSW)
Entity Type:Individual
Prefix:
First Name:ZACHARY
Middle Name:
Last Name:MOORE
Suffix:
Gender:M
Credentials:LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:885 COMMERCE DR
Mailing Address - Street 2:
Mailing Address - City:PERRYSBURG
Mailing Address - State:OH
Mailing Address - Zip Code:43551-5267
Mailing Address - Country:US
Mailing Address - Phone:419-330-1649
Mailing Address - Fax:
Practice Address - Street 1:4600 CARNEGIE AVE
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44103-4371
Practice Address - Country:US
Practice Address - Phone:216-431-7571
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-10-11
Last Update Date:2017-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHS.1700741104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker