Provider Demographics
NPI:1508923152
Name:MOORE, HENRIETTA LOUISE (MED,LMFT)
Entity Type:Individual
Prefix:MRS
First Name:HENRIETTA
Middle Name:LOUISE
Last Name:MOORE
Suffix:
Gender:F
Credentials:MED,LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5244 DEERFIELD PARK CT NE
Mailing Address - Street 2:
Mailing Address - City:OLYMPIA
Mailing Address - State:WA
Mailing Address - Zip Code:98516-2131
Mailing Address - Country:US
Mailing Address - Phone:360-491-7212
Mailing Address - Fax:
Practice Address - Street 1:612 CARPENTER RD SE
Practice Address - Street 2:
Practice Address - City:OLYMPIA
Practice Address - State:WA
Practice Address - Zip Code:98503-1383
Practice Address - Country:US
Practice Address - Phone:360-951-7540
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALF00001032106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist