Provider Demographics
NPI:1568737252
Name:MOORE, CHARLOTTE J (LCPC, CADC)
Entity Type:Individual
Prefix:
First Name:CHARLOTTE
Middle Name:J
Last Name:MOORE
Suffix:
Gender:F
Credentials:LCPC, CADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5537 N BROADWAY ST
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60640-1405
Mailing Address - Country:US
Mailing Address - Phone:773-989-9400
Mailing Address - Fax:773-989-9494
Practice Address - Street 1:5537 N BROADWAY ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60640-1405
Practice Address - Country:US
Practice Address - Phone:773-989-9400
Practice Address - Fax:773-989-9494
Is Sole Proprietor?:No
Enumeration Date:2012-03-14
Last Update Date:2012-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL17678101YA0400X
IL180.005476101YM0800X, 101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health