Provider Demographics
NPI:1225356348
Name:MOORE, TIMOTHY (LCPC)
Entity Type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:
Last Name:MOORE
Suffix:
Gender:M
Credentials:LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:450 W 14TH ST
Mailing Address - Street 2:
Mailing Address - City:CHICAGO HEIGHTS
Mailing Address - State:IL
Mailing Address - Zip Code:60411-2463
Mailing Address - Country:US
Mailing Address - Phone:708-503-9670
Mailing Address - Fax:
Practice Address - Street 1:450 W 14TH ST
Practice Address - Street 2:
Practice Address - City:CHICAGO HEIGHTS
Practice Address - State:IL
Practice Address - Zip Code:60411-2463
Practice Address - Country:US
Practice Address - Phone:708-503-9670
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-05-13
Last Update Date:2010-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL180001082101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor