Provider Demographics
NPI:1790826477
Name:MOORE, MARK (LCPC)
Entity Type:Individual
Prefix:MR
First Name:MARK
Middle Name:
Last Name:MOORE
Suffix:
Gender:M
Credentials:LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:500 N MICHIGAN AVE
Mailing Address - Street 2:SUITE 300
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60611-3777
Mailing Address - Country:US
Mailing Address - Phone:708-229-2778
Mailing Address - Fax:
Practice Address - Street 1:500 N MICHIGAN AVE
Practice Address - Street 2:SUITE 300
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60611-3777
Practice Address - Country:US
Practice Address - Phone:708-229-2778
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL101YP2500X, 103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Not Answered103T00000XBehavioral Health & Social Service ProvidersPsychologist