Provider Demographics
NPI:1821872185
Name:MOORE, GRACE KATHLEEN (MA, NCC)
Entity Type:Individual
Prefix:
First Name:GRACE
Middle Name:KATHLEEN
Last Name:MOORE
Suffix:
Gender:F
Credentials:MA, NCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1112 BERTLING ST APT 221
Mailing Address - Street 2:
Mailing Address - City:CAPE GIRARDEAU
Mailing Address - State:MO
Mailing Address - Zip Code:63701-3072
Mailing Address - Country:US
Mailing Address - Phone:314-497-0918
Mailing Address - Fax:
Practice Address - Street 1:339 BROADWAY ST STE 102
Practice Address - Street 2:
Practice Address - City:CAPE GIRARDEAU
Practice Address - State:MO
Practice Address - Zip Code:63701-7321
Practice Address - Country:US
Practice Address - Phone:573-271-2008
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-08-18
Last Update Date:2023-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health