Provider Demographics
NPI:1760843676
Name:MORO, PABLO ENRIQUE (LCSW, CSOTP)
Entity Type:Individual
Prefix:
First Name:PABLO
Middle Name:ENRIQUE
Last Name:MORO
Suffix:
Gender:M
Credentials:LCSW, CSOTP
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 523421
Mailing Address - Street 2:ATTN CARMEN WYMAN
Mailing Address - City:SPRINGFIELD
Mailing Address - State:VA
Mailing Address - Zip Code:22152-5421
Mailing Address - Country:US
Mailing Address - Phone:703-339-6471
Mailing Address - Fax:703-339-5651
Practice Address - Street 1:5415-C BACKLICK RD
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:VA
Practice Address - Zip Code:22151
Practice Address - Country:US
Practice Address - Phone:703-339-6471
Practice Address - Fax:703-339-5651
Is Sole Proprietor?:Yes
Enumeration Date:2016-03-19
Last Update Date:2016-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0812000185101YM0800X
VA09040031411041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health