Provider Demographics
NPI:1124225537
Name:MOORE, KATHERINE MADSEN (LPC)
Entity Type:Individual
Prefix:
First Name:KATHERINE
Middle Name:MADSEN
Last Name:MOORE
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19441 GOLF VISTA PLZ
Mailing Address - Street 2:SUITE 110
Mailing Address - City:LEESBURG
Mailing Address - State:VA
Mailing Address - Zip Code:20176-8269
Mailing Address - Country:US
Mailing Address - Phone:703-554-3260
Mailing Address - Fax:703-729-8836
Practice Address - Street 1:19441 GOLF VISTA PLZ
Practice Address - Street 2:SUITE 110
Practice Address - City:LEESBURG
Practice Address - State:VA
Practice Address - Zip Code:20176-8269
Practice Address - Country:US
Practice Address - Phone:703-554-3260
Practice Address - Fax:703-729-8836
Is Sole Proprietor?:No
Enumeration Date:2007-06-29
Last Update Date:2009-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0701004211101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA11758310OtherCAQH ID
VA0701004211OtherLPC LICENSE NUMBER