Provider Demographics
NPI:1609480243
Name:SMITH-MOORE, JOHN PATRICK (LCSW)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:PATRICK
Last Name:SMITH-MOORE
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5340 N CLARK ST STE 212
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60640-2120
Mailing Address - Country:US
Mailing Address - Phone:312-379-9476
Mailing Address - Fax:
Practice Address - Street 1:5340 N CLARK ST STE 212
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60640-2120
Practice Address - Country:US
Practice Address - Phone:312-379-9476
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-01
Last Update Date:2023-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL149.0197421041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical