Provider Demographics
NPI:1154673184
Name:MOORE, MYRA MARIE
Entity Type:Individual
Prefix:
First Name:MYRA
Middle Name:MARIE
Last Name:MOORE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MYRA
Other - Middle Name:MARIE
Other - Last Name:BEAM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 211
Mailing Address - Street 2:
Mailing Address - City:MOUNT NEBO
Mailing Address - State:WV
Mailing Address - Zip Code:26679-0211
Mailing Address - Country:US
Mailing Address - Phone:304-719-9701
Mailing Address - Fax:304-872-4453
Practice Address - Street 1:402 CHURCH ST STE 2
Practice Address - Street 2:
Practice Address - City:SUMMERSVILLE
Practice Address - State:WV
Practice Address - Zip Code:26651-1495
Practice Address - Country:US
Practice Address - Phone:304-256-4555
Practice Address - Fax:304-256-4715
Is Sole Proprietor?:No
Enumeration Date:2012-10-15
Last Update Date:2023-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV22070103TS0200X, 103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool