Provider Demographics
NPI:1235158627
Name:CALLARD-MOORE, THERESA MARIE (PHD, MSW, ACSW)
Entity Type:Individual
Prefix:
First Name:THERESA
Middle Name:MARIE
Last Name:CALLARD-MOORE
Suffix:
Gender:F
Credentials:PHD, MSW, ACSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9500 EUCLID AVE
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44195-0001
Mailing Address - Country:US
Mailing Address - Phone:734-936-2047
Mailing Address - Fax:
Practice Address - Street 1:9500 EUCLID AVE
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44195-0001
Practice Address - Country:US
Practice Address - Phone:216-444-2200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-18
Last Update Date:2023-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010670981041C0700X
IL149.0232421041C0700X
OHS.23097831041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI8008976950OtherBLUE CROSS
MI820555231OtherSHANTI COUNSELING TAX ID
MI820555231OtherSHANTI COUNSELING TAX ID
MION94700Medicare ID - Type UnspecifiedGROUP NUMBER