Provider Demographics
NPI:1659663086
Name:SMITH MOORE, BEVERLY (PHD, LPC, CCMHC)
Entity type:Individual
Prefix:DR
First Name:BEVERLY
Middle Name:
Last Name:SMITH MOORE
Suffix:
Gender:F
Credentials:PHD, LPC, CCMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3135 DUKE DR
Mailing Address - Street 2:
Mailing Address - City:FAIRBURN
Mailing Address - State:GA
Mailing Address - Zip Code:30213-8302
Mailing Address - Country:US
Mailing Address - Phone:678-523-1715
Mailing Address - Fax:
Practice Address - Street 1:401 WESTPARK CT STE 200
Practice Address - Street 2:
Practice Address - City:PEACHTREE CITY
Practice Address - State:GA
Practice Address - Zip Code:30269-3572
Practice Address - Country:US
Practice Address - Phone:678-523-1715
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-05-03
Last Update Date:2025-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALPC003014171000000X, 101YA0400X, 101Y00000X, 171400000X, 101YM0800X, 106H00000X, 101YP2500X, 101YP1600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No171000000XOther Service ProvidersMilitary Health Care Provider
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No171400000XOther Service ProvidersHealth & Wellness Coach
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101YP1600XBehavioral Health & Social Service ProvidersCounselorPastoral
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003109153AMedicaid