Provider Demographics
NPI:1346258761
Name:MOORE, MARY ANN (LCSW)
Entity Type:Individual
Prefix:MRS
First Name:MARY
Middle Name:ANN
Last Name:MOORE
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:MRS
Other - First Name:MARY
Other - Middle Name:ANN
Other - Last Name:STACEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LCSW
Mailing Address - Street 1:3309 S KINGSHIGHWAY BLVD
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63139-1101
Mailing Address - Country:US
Mailing Address - Phone:314-534-9350
Mailing Address - Fax:314-533-6047
Practice Address - Street 1:3309 S KINGSHIGHWAY BLVD
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63139-1101
Practice Address - Country:US
Practice Address - Phone:314-534-9350
Practice Address - Fax:314-533-6047
Is Sole Proprietor?:No
Enumeration Date:2006-08-03
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO0045641041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical