Healthcare Provider Details

I. General information

NPI: 1902459480
Provider Name (Legal Business Name): COOPER THOMAS MOORE LMHC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/23/2019
Last Update Date: 10/30/2023
Certification Date: 10/30/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1301 PLANTATION ISLAND DR S STE 202A
ST AUGUSTINE FL
32080-3111
US

IV. Provider business mailing address

1301 PLANTATION ISLAND DR S STE 202A
ST AUGUSTINE FL
32080-3111
US

V. Phone/Fax

Practice location:
  • Phone: 904-318-8500
  • Fax:
Mailing address:
  • Phone: 904-318-8500
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberMH18603
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number17529
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: