Provider Demographics
NPI:1811447584
Name:MOTLEY MOORE, MELISSA O (LPC)
Entity type:Individual
Prefix:
First Name:MELISSA
Middle Name:O
Last Name:MOTLEY MOORE
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1920 MATOAX AVE
Mailing Address - Street 2:
Mailing Address - City:PETERSBURG
Mailing Address - State:VA
Mailing Address - Zip Code:23805-2843
Mailing Address - Country:US
Mailing Address - Phone:804-467-5101
Mailing Address - Fax:
Practice Address - Street 1:1920 MATOAX AVE
Practice Address - Street 2:
Practice Address - City:PETERSBURG
Practice Address - State:VA
Practice Address - Zip Code:23805-2843
Practice Address - Country:US
Practice Address - Phone:804-467-5101
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-10-06
Last Update Date:2016-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0701006083101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional