Provider Demographics
NPI:1467549931
Name:MOORE, THERESA F (LPC)
Entity Type:Individual
Prefix:MRS
First Name:THERESA
Middle Name:F
Last Name:MOORE
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:MRS
Other - First Name:TRACEY
Other - Middle Name:F
Other - Last Name:MOORE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LPC
Mailing Address - Street 1:117A TRADEWYND DR
Mailing Address - Street 2:
Mailing Address - City:LYNCHBURG
Mailing Address - State:VA
Mailing Address - Zip Code:24502-3112
Mailing Address - Country:US
Mailing Address - Phone:434-426-1770
Mailing Address - Fax:
Practice Address - Street 1:117A TRADEWYND DR
Practice Address - Street 2:
Practice Address - City:LYNCHBURG
Practice Address - State:VA
Practice Address - Zip Code:24502-3112
Practice Address - Country:US
Practice Address - Phone:434-426-1770
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-06
Last Update Date:2014-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0701003209101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA218909OtherANTHEM BLUE SHIELD
VA004945441Medicaid
VAO84926OtherSENTARA