Provider Demographics
NPI:1073597696
Name:MOORE-MOTILY, SUSAN A (MA)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:A
Last Name:MOORE-MOTILY
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4124 RIDGEWOOD DR
Mailing Address - Street 2:
Mailing Address - City:ERIE
Mailing Address - State:PA
Mailing Address - Zip Code:16506-4090
Mailing Address - Country:US
Mailing Address - Phone:814-838-9155
Mailing Address - Fax:814-838-9097
Practice Address - Street 1:3939 W RIDGE RD
Practice Address - Street 2:STE A210
Practice Address - City:ERIE
Practice Address - State:PA
Practice Address - Zip Code:16506-1879
Practice Address - Country:US
Practice Address - Phone:814-838-9155
Practice Address - Fax:814-838-9097
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-12-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPS006812L103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA802324OtherHIGHMARK BC/BS PREMIER BL
PA211426OtherVALUE OPTIONS
PA500985OtherKEYSTONE HEALTH PLAN WEST
PA5732205OtherAETNA