Provider Demographics
NPI:1285931618
Name:MOORE, LENA (LSW)
Entity type:Individual
Prefix:
First Name:LENA
Middle Name:
Last Name:MOORE
Suffix:
Gender:F
Credentials:LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8411 S KIMBARK AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60619-6442
Mailing Address - Country:US
Mailing Address - Phone:773-879-8411
Mailing Address - Fax:
Practice Address - Street 1:8411 S KIMBARK AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60619-6442
Practice Address - Country:US
Practice Address - Phone:773-879-8411
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-02-21
Last Update Date:2011-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL150012896104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker