Provider Demographics
NPI:1811488034
Name:MOORE, DYLAN ANTHONY (LCSW)
Entity type:Individual
Prefix:MR
First Name:DYLAN
Middle Name:ANTHONY
Last Name:MOORE
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:483 N AVIATION BLVD
Mailing Address - Street 2:61 MDS/MENTAL HEALTH
Mailing Address - City:EL SEGUNDO
Mailing Address - State:CA
Mailing Address - Zip Code:90245-2808
Mailing Address - Country:US
Mailing Address - Phone:310-653-6448
Mailing Address - Fax:310-653-6737
Practice Address - Street 1:200 N DOUGLAS ST BLDG 210
Practice Address - Street 2:
Practice Address - City:EL SEGUNDO
Practice Address - State:CA
Practice Address - Zip Code:90245-4616
Practice Address - Country:US
Practice Address - Phone:310-653-6448
Practice Address - Fax:310-653-6737
Is Sole Proprietor?:No
Enumeration Date:2018-05-23
Last Update Date:2021-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALCSW951101041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical