Provider Demographics
NPI:1780199083
Name:MOORE, MILDRED PAULETTE (LISW-S)
Entity Type:Individual
Prefix:
First Name:MILDRED
Middle Name:PAULETTE
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 1:825 GRANDVIEW AVE
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43215-1123
Mailing Address - Country:US
Mailing Address - Phone:614-286-4390
Mailing Address - Fax:
Practice Address - Street 1:825 GRANDVIEW AVE
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43215-1123
Practice Address - Country:US
Practice Address - Phone:614-286-4390
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-12-08
Last Update Date:2017-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical