Provider Demographics
NPI:1548578800
Name:MOORE, WILLIAM CHARLES (LCSW)
Entity Type:Individual
Prefix:MR
First Name:WILLIAM
Middle Name:CHARLES
Last Name:MOORE
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:177 PRICE AVE
Mailing Address - Street 2:
Mailing Address - City:SOUTH SALT LAKE
Mailing Address - State:UT
Mailing Address - Zip Code:84115-4345
Mailing Address - Country:US
Mailing Address - Phone:801-718-0187
Mailing Address - Fax:801-269-7565
Practice Address - Street 1:177 PRICE AVE
Practice Address - Street 2:
Practice Address - City:SOUTH SALT LAKE
Practice Address - State:UT
Practice Address - Zip Code:84115-4345
Practice Address - Country:US
Practice Address - Phone:801-718-0187
Practice Address - Fax:801-269-7565
Is Sole Proprietor?:No
Enumeration Date:2010-09-21
Last Update Date:2010-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT340061-35011041S0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041S0200XBehavioral Health & Social Service ProvidersSocial WorkerSchool