Provider Demographics
NPI:1497887996
Name:MOORE, AMY L (LCSW)
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:L
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 1:307 HIGH ST
Mailing Address - Street 2:
Mailing Address - City:MARYVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37804-5847
Mailing Address - Country:US
Mailing Address - Phone:865-659-0834
Mailing Address - Fax:865-379-2869
Practice Address - Street 1:307 HIGH ST
Practice Address - Street 2:
Practice Address - City:MARYVILLE
Practice Address - State:TN
Practice Address - Zip Code:37804-5847
Practice Address - Country:US
Practice Address - Phone:865-659-0834
Practice Address - Fax:865-379-2869
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNLCSW00000038381041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN2024851OtherCIGNA BEHAVIORAL HEALTH
TN3097277OtherBLUECROSS BLUESHIELD ID