Provider Demographics
NPI:1265442131
Name:MOORE, GARY L (LCSW)
Entity Type:Individual
Prefix:
First Name:GARY
Middle Name:L
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:PO BOX 33
Mailing Address - Street 2:
Mailing Address - City:NORTH FORK
Mailing Address - State:ID
Mailing Address - Zip Code:83466-0033
Mailing Address - Country:US
Mailing Address - Phone:208-865-2100
Mailing Address - Fax:
Practice Address - Street 1:500 W FORT ST
Practice Address - Street 2:BOISE VAMC
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83702-4598
Practice Address - Country:US
Practice Address - Phone:208-422-1360
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLCSW 271361041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical