Healthcare Provider Details

I. General information

NPI: 1083162747
Provider Name (Legal Business Name): MARY MOORE LPCC/LICDC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/12/2016
Last Update Date: 08/15/2023
Certification Date: 08/15/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

446 MORGAN ST
CINCINNATI OH
45206-2348
US

IV. Provider business mailing address

4600 MONTGOMERY RD STE 400
CINCINNATI OH
45212-2600
US

V. Phone/Fax

Practice location:
  • Phone: 513-834-7063
  • Fax: 513-873-1567
Mailing address:
  • Phone: 833-510-4357
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberLICDC.161907
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberE.2202957
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: