Provider Demographics
NPI:1093836488
Name:MOYER, MARY JUDITH
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:JUDITH
Last Name:MOYER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:JUDITH
Other - Middle Name:
Other - Last Name:MOYER
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LMHC
Mailing Address - Street 1:235 S MAITLAND AVE
Mailing Address - Street 2:STE 104
Mailing Address - City:MAITLAND
Mailing Address - State:FL
Mailing Address - Zip Code:32751-6452
Mailing Address - Country:US
Mailing Address - Phone:407-719-9468
Mailing Address - Fax:
Practice Address - Street 1:235 S MAITLAND AVE
Practice Address - Street 2:STE 104
Practice Address - City:MAITLAND
Practice Address - State:FL
Practice Address - Zip Code:32751-5638
Practice Address - Country:US
Practice Address - Phone:407-719-9468
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH4930101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional