Provider Demographics
NPI:1598917395
Name:MOORE, CHESTER WYN (LCSW)
Entity Type:Individual
Prefix:MR
First Name:CHESTER
Middle Name:WYN
Last Name:MOORE
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:MR
Other - First Name:CHESTER
Other - Middle Name:W
Other - Last Name:MOORE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LCSW
Mailing Address - Street 1:1817 BURR OAK ST
Mailing Address - Street 2:
Mailing Address - City:ARLINGTON
Mailing Address - State:TX
Mailing Address - Zip Code:76012-5602
Mailing Address - Country:US
Mailing Address - Phone:817-879-8799
Mailing Address - Fax:817-633-2094
Practice Address - Street 1:1170 CORPORATE DR W
Practice Address - Street 2:SUITE 110
Practice Address - City:ARLINGTON
Practice Address - State:TX
Practice Address - Zip Code:76006-6882
Practice Address - Country:US
Practice Address - Phone:817-879-8799
Practice Address - Fax:817-633-2094
Is Sole Proprietor?:Yes
Enumeration Date:2008-10-13
Last Update Date:2010-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX505651041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical