Provider Demographics
NPI:1457596553
Name:MOORE, DEBRA J (EDS)
Entity Type:Individual
Prefix:
First Name:DEBRA
Middle Name:J
Last Name:MOORE
Suffix:
Gender:F
Credentials:EDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1501 SUMTER STREET
Mailing Address - Street 2:PASTORAL COUNSELING SERVICE
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29201-2829
Mailing Address - Country:US
Mailing Address - Phone:803-296-5879
Mailing Address - Fax:803-296-5061
Practice Address - Street 1:1501 SUMTER STREET
Practice Address - Street 2:PASTORAL COUNSELING SERVICE
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29201-2928
Practice Address - Country:US
Practice Address - Phone:803-296-5879
Practice Address - Fax:803-296-5061
Is Sole Proprietor?:No
Enumeration Date:2008-12-04
Last Update Date:2015-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC528101YP2500X
SC1505106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC1505OtherLICENSED MARRIAGE AND FAMILY THERAPIST