Provider Demographics
NPI:1578010435
Name:MOORE, ANDREA
Entity Type:Individual
Prefix:
First Name:ANDREA
Middle Name:
Last Name:MOORE
Suffix:
Gender:F
Credentials:
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 53529
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60653-0529
Mailing Address - Country:US
Mailing Address - Phone:773-641-7095
Mailing Address - Fax:
Practice Address - Street 1:12446 S LOOMIS ST
Practice Address - Street 2:
Practice Address - City:CALUMET PARK
Practice Address - State:IL
Practice Address - Zip Code:60827-5832
Practice Address - Country:US
Practice Address - Phone:773-641-7095
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-07
Last Update Date:2016-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL149.0161581041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical