Provider Demographics
NPI:1952609778
Name:MOORE-POPE, SANDRA LYNNE (LCSW)
Entity Type:Individual
Prefix:MS
First Name:SANDRA
Middle Name:LYNNE
Last Name:MOORE-POPE
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2246 SHASTA WAY NE
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30345-2604
Mailing Address - Country:US
Mailing Address - Phone:404-309-6397
Mailing Address - Fax:404-471-1723
Practice Address - Street 1:2246 SHASTA WAY NE
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30345-2604
Practice Address - Country:US
Practice Address - Phone:404-309-6397
Practice Address - Fax:404-471-1723
Is Sole Proprietor?:Yes
Enumeration Date:2011-03-02
Last Update Date:2011-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACSW0040941041C0700X
TX091301041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0642464-01Medicaid