Provider Demographics
NPI:1245433366
Name:MOORE-SMITH, MARLO (BS)
Entity type:Individual
Prefix:MS
First Name:MARLO
Middle Name:
Last Name:MOORE-SMITH
Suffix:
Gender:F
Credentials:BS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:302 ERSKINE AVE
Mailing Address - Street 2:
Mailing Address - City:KODIAK
Mailing Address - State:AK
Mailing Address - Zip Code:99615-6341
Mailing Address - Country:US
Mailing Address - Phone:907-486-6181
Mailing Address - Fax:907-486-4503
Practice Address - Street 1:302 ERSKINE AVE
Practice Address - Street 2:
Practice Address - City:KODIAK
Practice Address - State:AK
Practice Address - Zip Code:99615-6341
Practice Address - Country:US
Practice Address - Phone:907-486-6181
Practice Address - Fax:907-486-4503
Is Sole Proprietor?:No
Enumeration Date:2007-06-06
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKCMG6469Medicaid