Provider Demographics
NPI:1629442231
Name:SMITH-MOORE, SEAN (LCSW)
Entity Type:Individual
Prefix:
First Name:SEAN
Middle Name:
Last Name:SMITH-MOORE
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:SEAN
Other - Middle Name:
Other - Last Name:SMITH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LCSW
Mailing Address - Street 1:5068 N WINCHESTER AVE APT 3N
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60640-7896
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4309 N KENMORE AVE UNIT 2
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60613-7352
Practice Address - Country:US
Practice Address - Phone:301-974-5985
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-11-19
Last Update Date:2021-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL34978101YA0400X
DCLG50081367104100000X
MD20792104100000X
IL1490196781041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No104100000XBehavioral Health & Social Service ProvidersSocial Worker