Provider Demographics
NPI:1598201659
Name:MOORE, MARIAH JANINE (SWT)
Entity Type:Individual
Prefix:
First Name:MARIAH
Middle Name:JANINE
Last Name:MOORE
Suffix:
Gender:F
Credentials:SWT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:314 IRMA DR
Mailing Address - Street 2:
Mailing Address - City:CHARDON
Mailing Address - State:OH
Mailing Address - Zip Code:44024-1424
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:401 SOUTH ST
Practice Address - Street 2:4A
Practice Address - City:CHARDON
Practice Address - State:OH
Practice Address - Zip Code:44024
Practice Address - Country:US
Practice Address - Phone:440-285-2170
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-01-13
Last Update Date:2021-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHI.21030061041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHS.1610524-TRNEMedicaid