Provider Demographics
NPI:1831172436
Name:STEVENSON MOORE, SUSAN ELIZABETH (MSW LCSW)
Entity type:Individual
Prefix:MRS
First Name:SUSAN
Middle Name:ELIZABETH
Last Name:STEVENSON MOORE
Suffix:
Gender:F
Credentials:MSW LCSW
Other - Prefix:
Other - First Name:SUSAN
Other - Middle Name:ELIZABETH
Other - Last Name:MOORE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MSW, LCSW
Mailing Address - Street 1:745 CRAIG RD STE 104
Mailing Address - Street 2:
Mailing Address - City:CREVE COEUR
Mailing Address - State:MO
Mailing Address - Zip Code:63141-7122
Mailing Address - Country:US
Mailing Address - Phone:314-606-1265
Mailing Address - Fax:314-202-6016
Practice Address - Street 1:745 CRAIG RD STE 104
Practice Address - Street 2:
Practice Address - City:CREVE COEUR
Practice Address - State:MO
Practice Address - Zip Code:63141-7122
Practice Address - Country:US
Practice Address - Phone:314-606-1265
Practice Address - Fax:314-202-6016
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-29
Last Update Date:2020-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO0062561041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO809003268Medicare PIN