Provider Demographics
NPI:1316234750
Name:MOORE, MARY (LCSW-C)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:MOORE
Suffix:
Gender:F
Credentials:LCSW-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:49 OLD SOLOMONS ISLAND RD
Mailing Address - Street 2:SUITE 200
Mailing Address - City:ANNAPOLIS
Mailing Address - State:MD
Mailing Address - Zip Code:21401-3854
Mailing Address - Country:US
Mailing Address - Phone:410-980-3155
Mailing Address - Fax:410-266-5328
Practice Address - Street 1:49 OLD SOLOMONS ISLAND RD
Practice Address - Street 2:SUITE 200
Practice Address - City:ANNAPOLIS
Practice Address - State:MD
Practice Address - Zip Code:21401-3854
Practice Address - Country:US
Practice Address - Phone:410-980-3155
Practice Address - Fax:410-266-5328
Is Sole Proprietor?:Yes
Enumeration Date:2011-07-06
Last Update Date:2017-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD203391041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAQ45561AMedicare PIN