Provider Demographics
NPI:1427062165
Name:MOORE, DEREK DYKES (LICSW)
Entity type:Individual
Prefix:MR
First Name:DEREK
Middle Name:DYKES
Last Name:MOORE
Suffix:
Gender:M
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10 BRIDGE ST
Mailing Address - Street 2:
Mailing Address - City:MARBLEHEAD
Mailing Address - State:MA
Mailing Address - Zip Code:01945-3711
Mailing Address - Country:US
Mailing Address - Phone:617-893-2231
Mailing Address - Fax:617-623-1817
Practice Address - Street 1:22 MCGRATH HWY
Practice Address - Street 2:
Practice Address - City:SOMERVILLE
Practice Address - State:MA
Practice Address - Zip Code:02143-4508
Practice Address - Country:US
Practice Address - Phone:617-623-1814
Practice Address - Fax:617-623-1817
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1133051041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical