Provider Demographics
NPI:1013993328
Name:MOORE, JOHN D (LCPC)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:D
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 1:4343 N CLARENDON AVE
Mailing Address - Street 2:#2212
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60613-2698
Mailing Address - Country:US
Mailing Address - Phone:773-704-5300
Mailing Address - Fax:
Practice Address - Street 1:4343 N CLARENDON AVE
Practice Address - Street 2:#2212
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60613-2698
Practice Address - Country:US
Practice Address - Phone:773-704-5300
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL01635350OtherBLUE CROSS BLUE SHIELD