Provider Demographics
NPI:1427503564
Name:MOORE, KEONA
Entity type:Individual
Prefix:
First Name:KEONA
Middle Name:
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 1:2845 E 77TH ST APT 110
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60649-4830
Mailing Address - Country:US
Mailing Address - Phone:708-439-0832
Mailing Address - Fax:
Practice Address - Street 1:2845 E 77TH ST APT 110
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60649-4830
Practice Address - Country:US
Practice Address - Phone:708-439-0832
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-08-18
Last Update Date:2016-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker