Provider Demographics
NPI:1518022458
Name:MOORE, PATRICK MICHAEL (ACSW, LCSW)
Entity Type:Individual
Prefix:
First Name:PATRICK
Middle Name:MICHAEL
Last Name:MOORE
Suffix:
Gender:M
Credentials:ACSW, LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1700 E 38TH ST
Mailing Address - Street 2:
Mailing Address - City:MARION
Mailing Address - State:IN
Mailing Address - Zip Code:46953-4568
Mailing Address - Country:US
Mailing Address - Phone:765-674-3321
Mailing Address - Fax:765-677-5115
Practice Address - Street 1:1700 E 38TH ST
Practice Address - Street 2:
Practice Address - City:MARION
Practice Address - State:IN
Practice Address - Zip Code:46953-4568
Practice Address - Country:US
Practice Address - Phone:765-674-3321
Practice Address - Fax:765-677-5115
Is Sole Proprietor?:No
Enumeration Date:2006-12-22
Last Update Date:2013-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN34001741101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000328198OtherBCBS
IN216970AMedicare ID - Type Unspecified