Provider Demographics
NPI:1275003410
Name:MOORE, MOLLY (LPC)
Entity Type:Individual
Prefix:MRS
First Name:MOLLY
Middle Name:
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 1:7925 S BROADWAY AVE STE 820
Mailing Address - Street 2:
Mailing Address - City:TYLER
Mailing Address - State:TX
Mailing Address - Zip Code:75703-5255
Mailing Address - Country:US
Mailing Address - Phone:903-561-8955
Mailing Address - Fax:903-561-8895
Practice Address - Street 1:7925 S BROADWAY AVE STE 820
Practice Address - Street 2:
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75703-5255
Practice Address - Country:US
Practice Address - Phone:903-561-8955
Practice Address - Fax:903-561-8895
Is Sole Proprietor?:Yes
Enumeration Date:2018-11-30
Last Update Date:2018-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor