Provider Demographics
NPI:1710154018
Name:MOORE, AMY LEE (MA,LPC)
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:LEE
Last Name:MOORE
Suffix:
Gender:F
Credentials:MA,LPC
Other - Prefix:
Other - First Name:AMY
Other - Middle Name:LEE
Other - Last Name:BRANSCUM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:220 RUSKIN DRIVE
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80910
Mailing Address - Country:US
Mailing Address - Phone:719-572-6100
Mailing Address - Fax:
Practice Address - Street 1:875 W. MORENO
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80905
Practice Address - Country:US
Practice Address - Phone:719-572-6100
Practice Address - Fax:719-572-6299
Is Sole Proprietor?:No
Enumeration Date:2008-05-15
Last Update Date:2014-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171M00000X, 101YM0800X
COLPC.0012016101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health