Healthcare Provider Details

I. General information

NPI: 1184079873
Provider Name (Legal Business Name): STACEY MARIE MOORE LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/29/2016
Last Update Date: 04/29/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1509 MAPLE ST
SCRANTON PA
18505-2707
US

IV. Provider business mailing address

736 W OAK ST
OLD FORGE PA
18518-1124
US

V. Phone/Fax

Practice location:
  • Phone: 570-342-8305
  • Fax:
Mailing address:
  • Phone: 570-430-4429
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberPC008107
License Number StatePA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: