Provider Demographics
NPI:1275966053
Name:MOORE, ASHLEY MIMS (LMFT)
Entity Type:Individual
Prefix:
First Name:ASHLEY
Middle Name:MIMS
Last Name:MOORE
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:205 S SKINNER AVE UNIT B
Mailing Address - Street 2:
Mailing Address - City:POOLER
Mailing Address - State:GA
Mailing Address - Zip Code:31322-3221
Mailing Address - Country:US
Mailing Address - Phone:912-349-8043
Mailing Address - Fax:
Practice Address - Street 1:205 S SKINNER AVE UNIT B
Practice Address - Street 2:
Practice Address - City:POOLER
Practice Address - State:GA
Practice Address - Zip Code:31322
Practice Address - Country:US
Practice Address - Phone:912-349-8043
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-08-15
Last Update Date:2019-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAMFT001331106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist