Provider Demographics
NPI:1174956635
Name:MOORE, MARIA A (ICS)
Entity type:Individual
Prefix:MRS
First Name:MARIA
Middle Name:A
Last Name:MOORE
Suffix:
Gender:F
Credentials:ICS
Other - Prefix:MRS
Other - First Name:MARIA
Other - Middle Name:A
Other - Last Name:MELENDEZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CSIT
Mailing Address - Street 1:2319 W CAPITOL DR
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53206-1919
Mailing Address - Country:US
Mailing Address - Phone:414-442-2033
Mailing Address - Fax:414-442-2167
Practice Address - Street 1:2319 W CAPITOL DR
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53206-1919
Practice Address - Country:US
Practice Address - Phone:414-442-2033
Practice Address - Fax:414-442-2167
Is Sole Proprietor?:No
Enumeration Date:2013-08-19
Last Update Date:2017-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI15585-132101YA0400X
WI15431-134101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)