Provider Demographics
NPI:1518125590
Name:MOORE, VIVIAN MARIE (LCPC)
Entity Type:Individual
Prefix:
First Name:VIVIAN
Middle Name:MARIE
Last Name:MOORE
Suffix:
Gender:F
Credentials:LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 5354
Mailing Address - Street 2:
Mailing Address - City:LANSING
Mailing Address - State:IL
Mailing Address - Zip Code:60438-5354
Mailing Address - Country:US
Mailing Address - Phone:312-714-8372
Mailing Address - Fax:
Practice Address - Street 1:132 E 79TH ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60619-2302
Practice Address - Country:US
Practice Address - Phone:773-487-0515
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-05-27
Last Update Date:2008-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL180.006905101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional