Provider Demographics
NPI:1720538911
Name:MOORE, TYRA (LICSW, LCSW-C)
Entity Type:Individual
Prefix:MS
First Name:TYRA
Middle Name:
Last Name:MOORE
Suffix:
Gender:F
Credentials:LICSW, LCSW-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7605 E ARBORY CT
Mailing Address - Street 2:
Mailing Address - City:LAUREL
Mailing Address - State:MD
Mailing Address - Zip Code:20707-5527
Mailing Address - Country:US
Mailing Address - Phone:571-247-8039
Mailing Address - Fax:
Practice Address - Street 1:9332 ANNAPOLIS RD
Practice Address - Street 2:#309
Practice Address - City:LANHAM
Practice Address - State:MD
Practice Address - Zip Code:20706-3113
Practice Address - Country:US
Practice Address - Phone:301-710-9400
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-10-11
Last Update Date:2016-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCLC500784731041C0700X
MD143431041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical