Provider Demographics
NPI:1164078127
Name:MOORE, SONYA SUSAN (LCSW)
Entity Type:Individual
Prefix:MRS
First Name:SONYA
Middle Name:SUSAN
Last Name:MOORE
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1118 FAIRWAY DR
Mailing Address - Street 2:
Mailing Address - City:CHESAPEAKE
Mailing Address - State:VA
Mailing Address - Zip Code:23320-9439
Mailing Address - Country:US
Mailing Address - Phone:860-287-1103
Mailing Address - Fax:
Practice Address - Street 1:1015 EDEN WAY N STE B
Practice Address - Street 2:
Practice Address - City:CHESAPEAKE
Practice Address - State:VA
Practice Address - Zip Code:23320-2787
Practice Address - Country:US
Practice Address - Phone:757-609-2726
Practice Address - Fax:757-609-2874
Is Sole Proprietor?:No
Enumeration Date:2019-08-15
Last Update Date:2019-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA09040111461041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1538503750Medicaid