Provider Demographics
NPI:1508629254
Name:MOORE, THEOLA (MS, MHC)
Entity Type:Individual
Prefix:MS
First Name:THEOLA
Middle Name:
Last Name:MOORE
Suffix:
Gender:F
Credentials:MS, MHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2700 NW 62ND ST STE B100
Mailing Address - Street 2:
Mailing Address - City:FORT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33309-1718
Mailing Address - Country:US
Mailing Address - Phone:754-900-0503
Mailing Address - Fax:754-289-4250
Practice Address - Street 1:2700 NW 62ND ST
Practice Address - Street 2:
Practice Address - City:FORT LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33309-1744
Practice Address - Country:US
Practice Address - Phone:754-900-0503
Practice Address - Fax:754-289-4250
Is Sole Proprietor?:Yes
Enumeration Date:2024-02-05
Last Update Date:2024-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health