Healthcare Provider Details

I. General information

NPI: 1881513588
Provider Name (Legal Business Name): STEPHANIE MOORE LAC
Entity Type: Individual
Gender:
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/15/2026
Last Update Date: 07/15/2026
Certification Date: 07/15/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

259 DELSEA DR
SEWELL NJ
08080-9401
US

IV. Provider business mailing address

77 TAILOR LN
SICKLERVILLE NJ
08081-5697
US

V. Phone/Fax

Practice location:
  • Phone: 856-881-1666
  • Fax:
Mailing address:
  • Phone: 856-275-3061
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number37AC008962000
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: