Provider Demographics
NPI:1578629309
Name:MOORE, MARY A (LCSW)
Entity Type:Individual
Prefix:MS
First Name:MARY
Middle Name:A
Last Name:MOORE
Suffix:
Gender:F
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:PO BOX 884
Mailing Address - Street 2:
Mailing Address - City:CIBOLO
Mailing Address - State:TX
Mailing Address - Zip Code:78108-0884
Mailing Address - Country:US
Mailing Address - Phone:210-313-3563
Mailing Address - Fax:210-599-9945
Practice Address - Street 1:19206 HUEBNER
Practice Address - Street 2:STE 104
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78258-9800
Practice Address - Country:US
Practice Address - Phone:210-313-3563
Practice Address - Fax:210-599-9945
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-28
Last Update Date:2017-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX96631041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1607459-01Medicaid
TX610010Medicare ID - Type Unspecified