Provider Demographics
NPI:1336596790
Name:MOORE, KIMBERLY (LCSW)
Entity type:Individual
Prefix:MISS
First Name:KIMBERLY
Middle Name:
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 1:223 WEST 131ST STREET
Mailing Address - Street 2:SUITE 1R
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10027
Mailing Address - Country:US
Mailing Address - Phone:347-423-2565
Mailing Address - Fax:
Practice Address - Street 1:117 W 130TH ST
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10027-2007
Practice Address - Country:US
Practice Address - Phone:347-423-2565
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-05-16
Last Update Date:2024-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY18852101YA0400X
NY0912341041C0700X
NY72093533104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical