Provider Demographics
NPI:1861113342
Name:MOORE, KEVIN M
Entity type:Individual
Prefix:
First Name:KEVIN
Middle Name:M
Last Name:MOORE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8102 HUNTERS GREEN CT
Mailing Address - Street 2:
Mailing Address - City:CLINTON
Mailing Address - State:MD
Mailing Address - Zip Code:20735-2989
Mailing Address - Country:US
Mailing Address - Phone:301-873-3552
Mailing Address - Fax:
Practice Address - Street 1:8118 GOOD LUCK RD
Practice Address - Street 2:
Practice Address - City:LANHAM
Practice Address - State:MD
Practice Address - Zip Code:20706-3574
Practice Address - Country:US
Practice Address - Phone:301-552-5187
Practice Address - Fax:301-552-8668
Is Sole Proprietor?:No
Enumeration Date:2022-09-05
Last Update Date:2022-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD110011041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD15680687Medicaid