Provider Demographics
NPI:1376097725
Name:MOORE, ROBIN (LCSW)
Entity Type:Individual
Prefix:
First Name:ROBIN
Middle Name:
Last Name:MOORE
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2700 E STATE ST
Mailing Address - Street 2:1W
Mailing Address - City:BURNHAM
Mailing Address - State:IL
Mailing Address - Zip Code:60633-2032
Mailing Address - Country:US
Mailing Address - Phone:773-387-7153
Mailing Address - Fax:
Practice Address - Street 1:2700 E STATE ST
Practice Address - Street 2:1W
Practice Address - City:BURNHAM
Practice Address - State:IL
Practice Address - Zip Code:60633-2032
Practice Address - Country:US
Practice Address - Phone:773-387-7153
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-14
Last Update Date:2016-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL18692101YA0400X
IL1490172721041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)