Provider Demographics
NPI:1285992396
Name:MOORE, MARY ELIZABETH (LCSW)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:ELIZABETH
Last Name:MOORE
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3660 STONERIDGE RD
Mailing Address - Street 2:BUILDING D102
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78746-7760
Mailing Address - Country:US
Mailing Address - Phone:512-328-5357
Mailing Address - Fax:512-328-9803
Practice Address - Street 1:3660 STONERIDGE RD
Practice Address - Street 2:BUILDING D102
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78746-7760
Practice Address - Country:US
Practice Address - Phone:512-328-5357
Practice Address - Fax:512-328-9803
Is Sole Proprietor?:Yes
Enumeration Date:2012-04-26
Last Update Date:2012-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX008591041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical