Provider Demographics
NPI:1720243926
Name:MOORE, DEBORAH LYNN (LPC, LCSW)
Entity Type:Individual
Prefix:MS
First Name:DEBORAH
Middle Name:LYNN
Last Name:MOORE
Suffix:
Gender:F
Credentials:LPC, LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1160 COUNTRY CLUB LN
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76112-2303
Mailing Address - Country:US
Mailing Address - Phone:817-496-9796
Mailing Address - Fax:
Practice Address - Street 1:1160 COUNTRY CLUB LN
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76112-2303
Practice Address - Country:US
Practice Address - Phone:817-496-9796
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-28
Last Update Date:2008-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX0005000101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX064289401Medicaid