Provider Demographics
NPI:1992929160
Name:MOORE, DAVID N (LSW)
Entity type:Individual
Prefix:
First Name:DAVID
Middle Name:N
Last Name:MOORE
Suffix:
Gender:M
Credentials:LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 21
Mailing Address - Street 2:
Mailing Address - City:BALSAM LAKE
Mailing Address - State:WI
Mailing Address - Zip Code:54810-0021
Mailing Address - Country:US
Mailing Address - Phone:715-485-9343
Mailing Address - Fax:
Practice Address - Street 1:100 POLK COUNTY PLZ
Practice Address - Street 2:SUITE 50
Practice Address - City:BALSAM LAKE
Practice Address - State:WI
Practice Address - Zip Code:54810-9071
Practice Address - Country:US
Practice Address - Phone:715-485-8414
Practice Address - Fax:715-485-8490
Is Sole Proprietor?:No
Enumeration Date:2007-04-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1109 120171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator