Provider Demographics
NPI:1659665750
Name:MOORE, TAMMY LYNN (LISW-S)
Entity Type:Individual
Prefix:
First Name:TAMMY
Middle Name:LYNN
Last Name:MOORE
Suffix:
Gender:F
Credentials:LISW-S
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1200 W 5TH AVE
Mailing Address - Street 2:SUITE 102-D
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43212-2503
Mailing Address - Country:US
Mailing Address - Phone:614-398-1180
Mailing Address - Fax:
Practice Address - Street 1:2700 E MAIN ST
Practice Address - Street 2:SUITE 102
Practice Address - City:BEXLEY
Practice Address - State:OH
Practice Address - Zip Code:43209-2536
Practice Address - Country:US
Practice Address - Phone:614-398-1180
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-06
Last Update Date:2012-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHI0700225-S1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical