Provider Demographics
NPI:1346647047
Name:MOORE, DE'LISA G (LSW)
Entity Type:Individual
Prefix:
First Name:DE'LISA
Middle Name:G
Last Name:MOORE
Suffix:
Gender:F
Credentials:LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:601 S EDWIN C MOSES BLVD - 4TH FLOOR NW BLDG
Mailing Address - Street 2:SAMARITAN BEHAVIORAL HEALTH, INC.
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45417-3424
Mailing Address - Country:US
Mailing Address - Phone:937-734-8333
Mailing Address - Fax:937-734-4343
Practice Address - Street 1:601 S EDWIN C MOSES BLVD - 4TH FLOOR NW BLDG
Practice Address - Street 2:SAMARITAN BEHAVIORAL HEALTH, INC.
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45417-3424
Practice Address - Country:US
Practice Address - Phone:937-734-8333
Practice Address - Fax:937-734-4343
Is Sole Proprietor?:No
Enumeration Date:2014-11-24
Last Update Date:2014-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHS.1101626104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker