Healthcare Provider Details

I. General information

NPI: 1366355182
Provider Name (Legal Business Name): MARY MELISSA MOORE MSW, LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/23/2026
Last Update Date: 09/23/2026
Certification Date: 09/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

46179 WESTLAKE DR STE 220
STERLING VA
20165-5874
US

IV. Provider business mailing address

8210 WINSTEAD PL APT 204
MANASSAS VA
20109-2790
US

V. Phone/Fax

Practice location:
  • Phone: 571-417-9929
  • Fax:
Mailing address:
  • Phone: 571-417-9929
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number0906016396
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: