Healthcare Provider Details

I. General information

NPI: 1679960082
Provider Name (Legal Business Name): VIRGINIA MOORE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/23/2015
Last Update Date: 05/01/2026
Certification Date: 05/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

522 W RIVERSIDE AVE STE N
SPOKANE WA
99201-0581
US

IV. Provider business mailing address

19980 10TH AVE NE STE 204G
POULSBO WA
98370-6431
US

V. Phone/Fax

Practice location:
  • Phone: 425-954-3194
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number61597872
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: