Provider Demographics
NPI:1194497974
Name:MOORE, MARY EVELYN
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:EVELYN
Last Name:MOORE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:48 MEDICAL PARK DR E
Mailing Address - Street 2:
Mailing Address - City:BIRMINGHAM
Mailing Address - State:AL
Mailing Address - Zip Code:35235-3400
Mailing Address - Country:US
Mailing Address - Phone:205-338-3349
Mailing Address - Fax:205-838-3451
Practice Address - Street 1:48 MEDICAL PARK DR E STE 159
Practice Address - Street 2:
Practice Address - City:BIRMINGHAM
Practice Address - State:AL
Practice Address - Zip Code:35235-3462
Practice Address - Country:US
Practice Address - Phone:205-338-3349
Practice Address - Fax:205-838-3451
Is Sole Proprietor?:No
Enumeration Date:2021-09-30
Last Update Date:2021-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL4585C1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical