Provider Demographics
NPI:1770258766
Name:MOORE, SUSANNA (MSM LPC)
Entity Type:Individual
Prefix:MS
First Name:SUSANNA
Middle Name:
Last Name:MOORE
Suffix:
Gender:F
Credentials:MSM LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2541 E INDIANA AVE
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19134-4940
Mailing Address - Country:US
Mailing Address - Phone:215-901-4658
Mailing Address - Fax:
Practice Address - Street 1:6930 MARKET ST FL 2
Practice Address - Street 2:
Practice Address - City:UPPER DARBY
Practice Address - State:PA
Practice Address - Zip Code:19082-2308
Practice Address - Country:US
Practice Address - Phone:484-469-4319
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-11
Last Update Date:2021-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPC013468101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional