Provider Demographics
NPI:1972657229
Name:MOORE, LISA JOY (MSS)
Entity Type:Individual
Prefix:MS
First Name:LISA
Middle Name:JOY
Last Name:MOORE
Suffix:
Gender:F
Credentials:MSS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7104 DOREL ST
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19153-2404
Mailing Address - Country:US
Mailing Address - Phone:215-937-1160
Mailing Address - Fax:
Practice Address - Street 1:1500 WALNUT ST STE 601
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19102-3516
Practice Address - Country:US
Practice Address - Phone:610-892-3800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-23
Last Update Date:2022-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
104100000X
PACW0191811041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker