Provider Demographics
NPI:1841220936
Name:MOORE, ELLEN (LCSW)
Entity Type:Individual
Prefix:
First Name:ELLEN
Middle Name:
Last Name:MOORE
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2972 OTIS ST
Mailing Address - Street 2:
Mailing Address - City:BERKELEY
Mailing Address - State:CA
Mailing Address - Zip Code:94703-2517
Mailing Address - Country:US
Mailing Address - Phone:510-841-2959
Mailing Address - Fax:
Practice Address - Street 1:3282 ADELINE ST
Practice Address - Street 2:
Practice Address - City:BERKELEY
Practice Address - State:CA
Practice Address - Zip Code:94703-2439
Practice Address - Country:US
Practice Address - Phone:510-981-5280
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALCS17591104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker