Provider Demographics
NPI:1316403041
Name:MOORE, MYRA O'BRIEN
Entity type:Individual
Prefix:MS
First Name:MYRA
Middle Name:O'BRIEN
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 1:10333 SERENADE CT.
Mailing Address - Street 2:
Mailing Address - City:CLINTON
Mailing Address - State:MD
Mailing Address - Zip Code:20735
Mailing Address - Country:US
Mailing Address - Phone:301-503-2624
Mailing Address - Fax:301-567-7900
Practice Address - Street 1:6188 OXON HILL ROAD
Practice Address - Street 2:SUITE 500
Practice Address - City:OXON HILL
Practice Address - State:MD
Practice Address - Zip Code:20745-3136
Practice Address - Country:US
Practice Address - Phone:301-567-0400
Practice Address - Fax:301-567-7900
Is Sole Proprietor?:No
Enumeration Date:2019-02-19
Last Update Date:2019-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDG062851041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical