Provider Demographics
NPI:1558829234
Name:MOORE, MATTHEW (LICSW)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:
Last Name:MOORE
Suffix:
Gender:M
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12714 NE 8TH CT
Mailing Address - Street 2:
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98685-3054
Mailing Address - Country:US
Mailing Address - Phone:512-636-4780
Mailing Address - Fax:
Practice Address - Street 1:9901 NE 7TH AVE STE A206
Practice Address - Street 2:
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98685-4526
Practice Address - Country:US
Practice Address - Phone:512-636-4780
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-12
Last Update Date:2024-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALW614185101041C0700X
171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical