Provider Demographics
NPI:1285864165
Name:KIRBY, MIA MOORE (LCSW)
Entity Type:Individual
Prefix:MRS
First Name:MIA
Middle Name:MOORE
Last Name:KIRBY
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:MIA
Other - Middle Name:
Other - Last Name:MOORE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:314 RIVERWALK LANE
Mailing Address - Street 2:
Mailing Address - City:IRVING
Mailing Address - State:TX
Mailing Address - Zip Code:75063
Mailing Address - Country:US
Mailing Address - Phone:972-861-0106
Mailing Address - Fax:505-814-5737
Practice Address - Street 1:9330 LYNDON B. JOHNSON FWY. #900
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75243
Practice Address - Country:US
Practice Address - Phone:972-861-0106
Practice Address - Fax:505-814-5737
Is Sole Proprietor?:Yes
Enumeration Date:2009-07-25
Last Update Date:2012-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
1041C0700X
TX555331041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX11992198OtherCAQH
TX0079XLMedicare UPIN