Provider Demographics
NPI:1336919406
Name:MOORE, NATALYA E
Entity Type:Individual
Prefix:
First Name:NATALYA
Middle Name:E
Last Name:MOORE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3701 ACADEMY AVE
Mailing Address - Street 2:
Mailing Address - City:PORTSMOUTH
Mailing Address - State:VA
Mailing Address - Zip Code:23703-3103
Mailing Address - Country:US
Mailing Address - Phone:757-550-8080
Mailing Address - Fax:
Practice Address - Street 1:3701 ACADEMY AVE
Practice Address - Street 2:
Practice Address - City:PORTSMOUTH
Practice Address - State:VA
Practice Address - Zip Code:23703-3103
Practice Address - Country:US
Practice Address - Phone:757-550-8080
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-01-08
Last Update Date:2024-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health