Provider Demographics
NPI:1073821963
Name:MOORE, CHARLOTTE A (PLPC)
Entity Type:Individual
Prefix:
First Name:CHARLOTTE
Middle Name:A
Last Name:MOORE
Suffix:
Gender:F
Credentials:PLPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:104 CRESCENT DR
Mailing Address - Street 2:
Mailing Address - City:LEBANON
Mailing Address - State:MO
Mailing Address - Zip Code:65536-3301
Mailing Address - Country:US
Mailing Address - Phone:417-588-5885
Mailing Address - Fax:417-588-4296
Practice Address - Street 1:104 CRESCENT DR
Practice Address - Street 2:
Practice Address - City:LEBANON
Practice Address - State:MO
Practice Address - Zip Code:65536-3301
Practice Address - Country:US
Practice Address - Phone:417-588-5885
Practice Address - Fax:417-588-4296
Is Sole Proprietor?:Yes
Enumeration Date:2010-09-14
Last Update Date:2011-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2010032196101YM0800X, 101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health