Provider Demographics
NPI:1871698621
Name:PRYOR-MOORE, DEBORAH (LICSW)
Entity type:Individual
Prefix:
First Name:DEBORAH
Middle Name:
Last Name:PRYOR-MOORE
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1350 BELMONT ST
Mailing Address - Street 2:SUITE 107
Mailing Address - City:BROCKTON
Mailing Address - State:MA
Mailing Address - Zip Code:02301-4430
Mailing Address - Country:US
Mailing Address - Phone:508-584-9161
Mailing Address - Fax:
Practice Address - Street 1:1350 BELMONT ST
Practice Address - Street 2:SUITE 107
Practice Address - City:BROCKTON
Practice Address - State:MA
Practice Address - Zip Code:02301-4430
Practice Address - Country:US
Practice Address - Phone:508-584-9161
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1068031041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0000PO4296OtherBC/BS PROVIDER NUMBER
MAP21083Medicare ID - Type UnspecifiedPROVIDER NUMBER