Provider Demographics
NPI:1891884383
Name:MOORE, JUDY IRENE (LISW)
Entity Type:Individual
Prefix:
First Name:JUDY
Middle Name:IRENE
Last Name:MOORE
Suffix:
Gender:F
Credentials:LISW
Other - Prefix:
Other - First Name:IRENE
Other - Middle Name:
Other - Last Name:MOORE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LISW
Mailing Address - Street 1:2830 VICTORY PKWY STE 120
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45206-1786
Mailing Address - Country:US
Mailing Address - Phone:513-245-3052
Mailing Address - Fax:
Practice Address - Street 1:UNIVERSITY FAMILY PHYSICIANS INC
Practice Address - Street 2:141 HEALTH PROF BLDG
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45267-0001
Practice Address - Country:US
Practice Address - Phone:513-558-4021
Practice Address - Fax:513-558-3030
Is Sole Proprietor?:No
Enumeration Date:2006-10-12
Last Update Date:2007-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHI-00038651041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHMOSW19692Medicare ID - Type Unspecified
S64491Medicare UPIN