Healthcare Provider Details

I. General information

NPI: 1053580258
Provider Name (Legal Business Name): EILEEN LOUISE MOORE MA, MS, LMHC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/21/2008
Last Update Date: 09/26/2024
Certification Date: 09/26/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6268 OLD BETHEL RD
CRESTVIEW FL
32536-5505
US

IV. Provider business mailing address

6268 OLD BETHEL RD
CRESTVIEW FL
32536-5505
US

V. Phone/Fax

Practice location:
  • Phone: 850-353-2677
  • Fax:
Mailing address:
  • Phone: 850-353-2677
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberMH9518
License Number State
# 2
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberMH9518
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: