Provider Demographics
NPI:1346318763
Name:MOORE, STUART COLEMAN (LCSW)
Entity Type:Individual
Prefix:MR
First Name:STUART
Middle Name:COLEMAN
Last Name:MOORE
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12050 S LAKES DR
Mailing Address - Street 2:
Mailing Address - City:RESTON
Mailing Address - State:VA
Mailing Address - Zip Code:20191-1220
Mailing Address - Country:US
Mailing Address - Phone:703-386-0050
Mailing Address - Fax:703-476-6013
Practice Address - Street 1:8101 HINSON FARM RD STE 117
Practice Address - Street 2:
Practice Address - City:ALEXANDRIA
Practice Address - State:VA
Practice Address - Zip Code:22306-3404
Practice Address - Country:US
Practice Address - Phone:703-386-0050
Practice Address - Fax:703-780-0947
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-01
Last Update Date:2018-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0904003326103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
011710K92Medicare ID - Type Unspecified