Provider Demographics
NPI:1457768855
Name:MOBERLY, ALLISON NICOLE (LCPC)
Entity Type:Individual
Prefix:
First Name:ALLISON
Middle Name:NICOLE
Last Name:MOBERLY
Suffix:
Gender:F
Credentials:LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:202 N MAIN ST APT L
Mailing Address - Street 2:
Mailing Address - City:PORT DEPOSIT
Mailing Address - State:MD
Mailing Address - Zip Code:21904-1292
Mailing Address - Country:US
Mailing Address - Phone:315-261-8202
Mailing Address - Fax:
Practice Address - Street 1:202 N MAIN ST APT L
Practice Address - Street 2:
Practice Address - City:PORT DEPOSIT
Practice Address - State:MD
Practice Address - Zip Code:21904-1292
Practice Address - Country:US
Practice Address - Phone:315-261-8202
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-07-17
Last Update Date:2020-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDLC10645101YP2500X
MD101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD520202700Medicaid
MD609550001Medicaid
MD520202701Medicaid
MD520202702Medicaid