Provider Demographics
NPI:1144961467
Name:MOORE, TRACEY (LCSW)
Entity type:Individual
Prefix:MS
First Name:TRACEY
Middle Name:
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 1:4625 LINDELL BLVD STE 200&300
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63108-3725
Mailing Address - Country:US
Mailing Address - Phone:636-674-9113
Mailing Address - Fax:
Practice Address - Street 1:4625 LINDELL BLVD
Practice Address - Street 2:STE 200&300
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63108-3725
Practice Address - Country:US
Practice Address - Phone:636-374-9113
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-04-02
Last Update Date:2022-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20200378951041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical