Provider Demographics
NPI:1730280108
Name:MOORE, WAYNE L (LCSW)
Entity Type:Individual
Prefix:
First Name:WAYNE
Middle Name:L
Last Name:MOORE
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:78 ATLANTIC PLACE
Mailing Address - Street 2:
Mailing Address - City:SOUTH PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04106-2316
Mailing Address - Country:US
Mailing Address - Phone:207-842-6556
Mailing Address - Fax:207-842-7773
Practice Address - Street 1:12 UNION STREET
Practice Address - Street 2:
Practice Address - City:ROCKLAND
Practice Address - State:ME
Practice Address - Zip Code:04841-2739
Practice Address - Country:US
Practice Address - Phone:207-701-4402
Practice Address - Fax:207-701-4486
Is Sole Proprietor?:No
Enumeration Date:2006-09-26
Last Update Date:2010-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LC56611041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME264310099Medicaid
ME104540000Medicaid
ME264310099Medicaid
ME104540000Medicaid