Provider Demographics
NPI:1447368162
Name:IRWIN MOORE, ELIZABETH C (LCSW)
Entity type:Individual
Prefix:MS
First Name:ELIZABETH
Middle Name:C
Last Name:IRWIN MOORE
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:ELIZABETH
Other - Middle Name:C
Other - Last Name:IRWIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LCSW
Mailing Address - Street 1:1220 DEWEY AVE
Mailing Address - Street 2:
Mailing Address - City:WAUWATOSA
Mailing Address - State:WI
Mailing Address - Zip Code:53213-2504
Mailing Address - Country:US
Mailing Address - Phone:414-454-6779
Mailing Address - Fax:
Practice Address - Street 1:1220 DEWEY AVE
Practice Address - Street 2:BLDG #3
Practice Address - City:WAUWATOSA
Practice Address - State:WI
Practice Address - Zip Code:53213
Practice Address - Country:US
Practice Address - Phone:414-454-6566
Practice Address - Fax:414-454-6522
Is Sole Proprietor?:No
Enumeration Date:2006-08-25
Last Update Date:2007-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI6763-1231041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI40912000Medicaid