Provider Demographics
NPI:1881264406
Name:MOORE, MAYA RENE (LICSW)
Entity type:Individual
Prefix:
First Name:MAYA
Middle Name:RENE
Last Name:MOORE
Suffix:
Gender:F
Credentials:LICSW
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 34703
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98124-1703
Mailing Address - Country:US
Mailing Address - Phone:206-764-0502
Mailing Address - Fax:206-764-0516
Practice Address - Street 1:1710 ALLEN ST
Practice Address - Street 2:
Practice Address - City:KELSO
Practice Address - State:WA
Practice Address - Zip Code:98626-4907
Practice Address - Country:US
Practice Address - Phone:360-261-7020
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-27
Last Update Date:2023-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALW613685751041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical