Provider Demographics
NPI:1598320236
Name:MOORE, CHERYL LYNNE (LCSW)
Entity Type:Individual
Prefix:MS
First Name:CHERYL
Middle Name:LYNNE
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 1:2904 SUDDERTH DR
Mailing Address - Street 2:SUITE B
Mailing Address - City:RUIDOSO
Mailing Address - State:NM
Mailing Address - Zip Code:88345
Mailing Address - Country:US
Mailing Address - Phone:575-491-3300
Mailing Address - Fax:844-876-6786
Practice Address - Street 1:2904 SUDDERTH DR
Practice Address - Street 2:SUITE B
Practice Address - City:RUIDOSO
Practice Address - State:NM
Practice Address - Zip Code:88345
Practice Address - Country:US
Practice Address - Phone:575-491-3300
Practice Address - Fax:844-876-6786
Is Sole Proprietor?:No
Enumeration Date:2019-05-08
Last Update Date:2019-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMC-09946104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker