Provider Demographics
NPI:1851333876
Name:MOORE, BRIAN LEN (LCSW)
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:LEN
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:PO BOX 6430
Mailing Address - Street 2:
Mailing Address - City:SPRINGDALE
Mailing Address - State:AR
Mailing Address - Zip Code:72766-6430
Mailing Address - Country:US
Mailing Address - Phone:479-750-2020
Mailing Address - Fax:479-756-3118
Practice Address - Street 1:3277 W SUNSET AVE
Practice Address - Street 2:
Practice Address - City:SPRINGDALE
Practice Address - State:AR
Practice Address - Zip Code:72762-4980
Practice Address - Country:US
Practice Address - Phone:479-750-2020
Practice Address - Fax:479-756-3118
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR1421-C1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR5W444Medicare ID - Type UnspecifiedMEDICARE PROVIDER #