Healthcare Provider Details

I. General information

NPI: 1033841291
Provider Name (Legal Business Name): LYDIA MOORE LCPC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/27/2022
Last Update Date: 05/29/2026
Certification Date: 05/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

253 LEWIS LN STE 101
HAVRE DE GRACE MD
21078-3755
US

IV. Provider business mailing address

253 LEWIS LN STE 101
HAVRE DE GRACE MD
21078-3755
US

V. Phone/Fax

Practice location:
  • Phone: 410-686-3629
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberLC15244
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: