Provider Demographics
NPI:1336462324
Name:MOORE, LISA LYNELLE (MSW, LICSW, PHD)
Entity Type:Individual
Prefix:MS
First Name:LISA
Middle Name:LYNELLE
Last Name:MOORE
Suffix:
Gender:F
Credentials:MSW, LICSW, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1304 LIBERTY CT
Mailing Address - Street 2:
Mailing Address - City:NORTHFIELD
Mailing Address - State:MN
Mailing Address - Zip Code:55057-2915
Mailing Address - Country:US
Mailing Address - Phone:503-528-4033
Mailing Address - Fax:
Practice Address - Street 1:2637 27TH AVE S STE 231
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55406-3196
Practice Address - Country:US
Practice Address - Phone:503-528-4033
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-03-05
Last Update Date:2018-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1156301041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical