Provider Demographics
NPI:1154827129
Name:KEVIN MOORE COUNSELING, LLC
Entity type:Organization
Organization Name:KEVIN MOORE COUNSELING, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:THERAPIST
Authorized Official - Prefix:MR
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:L
Authorized Official - Last Name:MOORE
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:574-529-5090
Mailing Address - Street 1:PO BOX 761
Mailing Address - Street 2:
Mailing Address - City:NORTH WEBSTER
Mailing Address - State:IN
Mailing Address - Zip Code:46555-0761
Mailing Address - Country:US
Mailing Address - Phone:574-529-5090
Mailing Address - Fax:
Practice Address - Street 1:313 S 3RD ST
Practice Address - Street 2:
Practice Address - City:GOSHEN
Practice Address - State:IN
Practice Address - Zip Code:46526-3709
Practice Address - Country:US
Practice Address - Phone:574-529-5090
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-03-30
Last Update Date:2018-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN34005489A1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty