Provider Demographics
NPI:1710443809
Name:MOORE, MELISSA ANN (LICSW)
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:ANN
Last Name:MOORE
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20 SCHOOL ST
Mailing Address - Street 2:
Mailing Address - City:LYNN
Mailing Address - State:MA
Mailing Address - Zip Code:01902-2952
Mailing Address - Country:US
Mailing Address - Phone:781-715-2393
Mailing Address - Fax:
Practice Address - Street 1:100 CUMMINGS CTR STE 166D
Practice Address - Street 2:
Practice Address - City:BEVERLY
Practice Address - State:MA
Practice Address - Zip Code:01915-6135
Practice Address - Country:US
Practice Address - Phone:978-712-3388
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-02-14
Last Update Date:2021-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1231411041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical