Provider Demographics
NPI:1629267547
Name:MOORE, SUSAN MANGUM (LPC)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:MANGUM
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:PO BOX 2738
Mailing Address - Street 2:
Mailing Address - City:PEMBROKE
Mailing Address - State:NC
Mailing Address - Zip Code:28372-2738
Mailing Address - Country:US
Mailing Address - Phone:910-785-2144
Mailing Address - Fax:
Practice Address - Street 1:4701 FAYETTEVILLE RD
Practice Address - Street 2:
Practice Address - City:LUMBERTON
Practice Address - State:NC
Practice Address - Zip Code:28358-2622
Practice Address - Country:US
Practice Address - Phone:910-735-1541
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-16
Last Update Date:2007-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC6607101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional