Provider Demographics
NPI:1467412403
Name:MOORE, AUDREY DURAND (LPC)
Entity Type:Individual
Prefix:MS
First Name:AUDREY
Middle Name:DURAND
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 1:703 THIMBLE SHOALS BLVD
Mailing Address - Street 2:SUITE A-3
Mailing Address - City:NEWPORT NEWS
Mailing Address - State:VA
Mailing Address - Zip Code:23606-2576
Mailing Address - Country:US
Mailing Address - Phone:757-873-2307
Mailing Address - Fax:757-873-3401
Practice Address - Street 1:703 THIMBLE SHOALS BLVD
Practice Address - Street 2:SUITE A-3
Practice Address - City:NEWPORT NEWS
Practice Address - State:VA
Practice Address - Zip Code:23606-2576
Practice Address - Country:US
Practice Address - Phone:757-873-2307
Practice Address - Fax:757-873-3401
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA07010022742101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA0101102189Medicaid