Provider Demographics
NPI:1649590563
Name:MOORE, MARY SHANNON (LCSW)
Entity Type:Individual
Prefix:MS
First Name:MARY
Middle Name:SHANNON
Last Name:MOORE
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:M.
Other - Middle Name:SHANNON
Other - Last Name:MOORE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LICSW
Mailing Address - Street 1:35 JOHN ST
Mailing Address - Street 2:
Mailing Address - City:LOWELL
Mailing Address - State:MA
Mailing Address - Zip Code:01852-1101
Mailing Address - Country:US
Mailing Address - Phone:978-275-3879
Mailing Address - Fax:978-275-6480
Practice Address - Street 1:35 JOHN ST
Practice Address - Street 2:
Practice Address - City:LOWELL
Practice Address - State:MA
Practice Address - Zip Code:01852-1101
Practice Address - Country:US
Practice Address - Phone:978-275-3879
Practice Address - Fax:978-275-6480
Is Sole Proprietor?:Yes
Enumeration Date:2010-06-02
Last Update Date:2014-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1182321041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical