Provider Demographics
NPI:1396143749
Name:MOORE, STEPHEN (LCSW)
Entity type:Individual
Prefix:
First Name:STEPHEN
Middle Name:
Last Name:MOORE
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3168 N WESTBURY WAY APT U2
Mailing Address - Street 2:
Mailing Address - City:LEHI
Mailing Address - State:UT
Mailing Address - Zip Code:84043-5814
Mailing Address - Country:US
Mailing Address - Phone:801-520-3970
Mailing Address - Fax:
Practice Address - Street 1:1404 W STATE RD
Practice Address - Street 2:
Practice Address - City:PLEASANT GROVE
Practice Address - State:UT
Practice Address - Zip Code:84062-5019
Practice Address - Country:US
Practice Address - Phone:801-520-3970
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-12-17
Last Update Date:2014-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT8005587-3501101YM0800X, 1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health