Provider Demographics
NPI:1508834961
Name:MOORE, SHONDA L (LSCSW)
Entity Type:Individual
Prefix:
First Name:SHONDA
Middle Name:L
Last Name:MOORE
Suffix:
Gender:F
Credentials:LSCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:807 N WACO AVE
Mailing Address - Street 2:STE 11
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67203-3971
Mailing Address - Country:US
Mailing Address - Phone:316-776-4360
Mailing Address - Fax:316-440-7054
Practice Address - Street 1:807 N WACO AVE
Practice Address - Street 2:STE 11
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67203-3971
Practice Address - Country:US
Practice Address - Phone:316-776-4360
Practice Address - Fax:316-440-7054
Is Sole Proprietor?:No
Enumeration Date:2006-03-10
Last Update Date:2018-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS37811041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical