Provider Demographics
NPI:1245517895
Name:MOORE, GEORGE J (LCSW)
Entity type:Individual
Prefix:
First Name:GEORGE
Middle Name:J
Last Name:MOORE
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1445 SEACREST LN APT 5
Mailing Address - Street 2:
Mailing Address - City:BROOKINGS
Mailing Address - State:OR
Mailing Address - Zip Code:97415-8133
Mailing Address - Country:US
Mailing Address - Phone:315-876-4419
Mailing Address - Fax:315-635-1865
Practice Address - Street 1:1445 SEACREST LN APT 5
Practice Address - Street 2:
Practice Address - City:BROOKINGS
Practice Address - State:OR
Practice Address - Zip Code:97415-8133
Practice Address - Country:US
Practice Address - Phone:315-876-4419
Practice Address - Fax:315-635-1865
Is Sole Proprietor?:Yes
Enumeration Date:2011-11-10
Last Update Date:2020-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY080335104100000X
CA930511041C0700X
NY0824001041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02994838OtherGRP MCD #
BA1047OtherGRP MCR #