Provider Demographics
NPI:1376983387
Name:MOORE, THERESA DENISE (EDD, LCPC)
Entity type:Individual
Prefix:DR
First Name:THERESA
Middle Name:DENISE
Last Name:MOORE
Suffix:
Gender:F
Credentials:EDD, LCPC
Other - Prefix:MS
Other - First Name:THERESA
Other - Middle Name:DENISE
Other - Last Name:EVERETT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:6909 W RAY RD STE 15-132
Mailing Address - Street 2:
Mailing Address - City:CHANDLER
Mailing Address - State:AZ
Mailing Address - Zip Code:85226-1699
Mailing Address - Country:US
Mailing Address - Phone:773-619-0985
Mailing Address - Fax:773-526-7634
Practice Address - Street 1:6909 W RAY RD STE 15-132
Practice Address - Street 2:
Practice Address - City:CHANDLER
Practice Address - State:AZ
Practice Address - Zip Code:85226-1699
Practice Address - Country:US
Practice Address - Phone:773-619-0985
Practice Address - Fax:773-526-7634
Is Sole Proprietor?:No
Enumeration Date:2013-07-05
Last Update Date:2022-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL178.007134101YM0800X, 101YP2500X
MIPC6401019591101YM0800X
AZLPC20270101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health