Provider Demographics
NPI:1255512612
Name:MOORE, MARSHELLE KATHERINE (LCSW)
Entity type:Individual
Prefix:MRS
First Name:MARSHELLE
Middle Name:KATHERINE
Last Name:MOORE
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:MISS
Other - First Name:MARSHELLE
Other - Middle Name:KATHERINE
Other - Last Name:PONCE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MSW
Mailing Address - Street 1:620 NW 16TH AVE
Mailing Address - Street 2:
Mailing Address - City:GAINESVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32601-4034
Mailing Address - Country:US
Mailing Address - Phone:352-376-8788
Mailing Address - Fax:
Practice Address - Street 1:620 NW 16TH AVE
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:FL
Practice Address - Zip Code:32601-4034
Practice Address - Country:US
Practice Address - Phone:352-376-8788
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-11-14
Last Update Date:2007-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSW63791041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLSW6379OtherLCSW