Provider Demographics
NPI:1922778935
Name:MOORE, LISA RENEE (LCSW)
Entity Type:Individual
Prefix:MRS
First Name:LISA
Middle Name:RENEE
Last Name:MOORE
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3005 TEASDALE RD
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:MS
Mailing Address - Zip Code:38921-9576
Mailing Address - Country:US
Mailing Address - Phone:662-809-0208
Mailing Address - Fax:
Practice Address - Street 1:3005 TEASDALE RD
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:MS
Practice Address - Zip Code:38921-9576
Practice Address - Country:US
Practice Address - Phone:662-809-0208
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-20
Last Update Date:2021-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSC22761041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical