Provider Demographics
NPI:1679016422
Name:MOORE, ELLEN (LMSW)
Entity Type:Individual
Prefix:DR
First Name:ELLEN
Middle Name:
Last Name:MOORE
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4304 S BEARFIELD RD
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:MO
Mailing Address - Zip Code:65201-9557
Mailing Address - Country:US
Mailing Address - Phone:573-874-8686
Mailing Address - Fax:573-874-8608
Practice Address - Street 1:4304 S BEARFIELD RD
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:MO
Practice Address - Zip Code:65201-9557
Practice Address - Country:US
Practice Address - Phone:573-874-8686
Practice Address - Fax:573-874-8608
Is Sole Proprietor?:No
Enumeration Date:2016-11-28
Last Update Date:2016-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2012014723104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker