Provider Demographics
NPI:1518649839
Name:MOORE, MICHELLE ALICIA (LCSW)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:ALICIA
Last Name:MOORE
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:707 GITTINGS ST STE 100
Mailing Address - Street 2:
Mailing Address - City:SUFFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23434-6101
Mailing Address - Country:US
Mailing Address - Phone:757-325-9570
Mailing Address - Fax:
Practice Address - Street 1:707 GITTINGS ST STE 100
Practice Address - Street 2:
Practice Address - City:SUFFOLK
Practice Address - State:VA
Practice Address - Zip Code:23434-6101
Practice Address - Country:US
Practice Address - Phone:757-325-9570
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-08-04
Last Update Date:2023-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA09040156371041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical