Provider Demographics
NPI:1457486250
Name:MOORE, SALLY ROBERTS (MRC, LMFT)
Entity Type:Individual
Prefix:MS
First Name:SALLY
Middle Name:ROBERTS
Last Name:MOORE
Suffix:
Gender:F
Credentials:MRC, LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 COLUMBIA ST
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32806-1006
Mailing Address - Country:US
Mailing Address - Phone:407-245-0014
Mailing Address - Fax:407-245-0015
Practice Address - Street 1:100 COLUMBIA ST
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32806-1006
Practice Address - Country:US
Practice Address - Phone:407-245-0014
Practice Address - Fax:407-245-0015
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMT655101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor