Provider Demographics
NPI:1417440397
Name:STUART MOORE LLC
Entity Type:Organization
Organization Name:STUART MOORE LLC
Other - Org Name:STUART MOORE LLC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:STUART
Authorized Official - Middle Name:COLEMAN
Authorized Official - Last Name:MOORE
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:703-386-0050
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 1:12050 S LAKES DR
Practice Address - Street 2:
Practice Address - City:RESTON
Practice Address - State:VA
Practice Address - Zip Code:20191-1220
Practice Address - Country:US
Practice Address - Phone:703-386-0050
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-06-14
Last Update Date:2018-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA09040033261041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1346318763OtherNPI