Provider Demographics
NPI:1881097699
Name:MOORE, ANTIONETTE C (LCSW)
Entity type:Individual
Prefix:
First Name:ANTIONETTE
Middle Name:C
Last Name:MOORE
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1209
Mailing Address - Street 2:
Mailing Address - City:TWENTYNINE PALMS
Mailing Address - State:CA
Mailing Address - Zip Code:92277-0980
Mailing Address - Country:US
Mailing Address - Phone:760-367-0730
Mailing Address - Fax:
Practice Address - Street 1:5715 UTAH TRL
Practice Address - Street 2:
Practice Address - City:TWENTYNINE PALMS
Practice Address - State:CA
Practice Address - Zip Code:92277-6917
Practice Address - Country:US
Practice Address - Phone:760-367-0730
Practice Address - Fax:760-367-0728
Is Sole Proprietor?:No
Enumeration Date:2014-10-07
Last Update Date:2018-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA790251041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical