Provider Demographics
NPI:1881659183
Name:MOORE, ELISABETH J (MS, LMHC)
Entity Type:Individual
Prefix:MS
First Name:ELISABETH
Middle Name:J
Last Name:MOORE
Suffix:
Gender:F
Credentials:MS, LMHC
Other - Prefix:
Other - First Name:LISA
Other - Middle Name:J
Other - Last Name:MOORE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MS, LMHC
Mailing Address - Street 1:PO BOX 1373
Mailing Address - Street 2:
Mailing Address - City:KEYSTONE HEIGHTS
Mailing Address - State:FL
Mailing Address - Zip Code:32656-1373
Mailing Address - Country:US
Mailing Address - Phone:904-269-2931
Mailing Address - Fax:904-269-2931
Practice Address - Street 1:1732 KINGSLEY AVE
Practice Address - Street 2:SUITE 1
Practice Address - City:ORANGE PARK
Practice Address - State:FL
Practice Address - Zip Code:32073-4412
Practice Address - Country:US
Practice Address - Phone:904-269-2931
Practice Address - Fax:904-269-2931
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-19
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH0002430101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL195812Medicare UPIN
FLZ3298Medicare UPIN