Provider Demographics
NPI:1528544723
Name:MOORE, VINETTA DENISE (LSW)
Entity Type:Individual
Prefix:
First Name:VINETTA
Middle Name:DENISE
Last Name:MOORE
Suffix:
Gender:F
Credentials:LSW
Other - Prefix:
Other - First Name:VINNETTA
Other - Middle Name:
Other - Last Name:SAMPLE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1075 HORACE ST
Mailing Address - Street 2:
Mailing Address - City:TOLEDO
Mailing Address - State:OH
Mailing Address - Zip Code:43606-4859
Mailing Address - Country:US
Mailing Address - Phone:419-475-4491
Mailing Address - Fax:
Practice Address - Street 1:3170 W CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:TOLEDO
Practice Address - State:OH
Practice Address - Zip Code:43606-2945
Practice Address - Country:US
Practice Address - Phone:419-214-5587
Practice Address - Fax:567-316-7253
Is Sole Proprietor?:Yes
Enumeration Date:2018-07-11
Last Update Date:2020-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
172V00000X
OHS.1904493104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No172V00000XOther Service ProvidersCommunity Health Worker