Provider Demographics
NPI:1588154611
Name:MOORE, MICHAEL (LCSW)
Entity type:Individual
Prefix:
First Name:MICHAEL
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 1:213 S DILLARD ST STE 120B
Mailing Address - Street 2:
Mailing Address - City:WINTER GARDEN
Mailing Address - State:FL
Mailing Address - Zip Code:34787-3596
Mailing Address - Country:US
Mailing Address - Phone:407-734-3338
Mailing Address - Fax:407-734-3338
Practice Address - Street 1:213 S DILLARD ST STE 120B
Practice Address - Street 2:
Practice Address - City:WINTER GARDEN
Practice Address - State:FL
Practice Address - Zip Code:34787-3596
Practice Address - Country:US
Practice Address - Phone:407-734-3338
Practice Address - Fax:407-734-3338
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-15
Last Update Date:2022-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical