Healthcare Provider Details

I. General information

NPI: 1154673184
Provider Name (Legal Business Name): MYRA MARIE MOORE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MYRA MARIE BEAM

II. Dates (important events)

Enumeration Date: 10/15/2012
Last Update Date: 08/15/2023
Certification Date: 08/15/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

402 CHURCH ST STE 2
SUMMERSVILLE WV
26651-1495
US

IV. Provider business mailing address

PO BOX 211
MOUNT NEBO WV
26679-0211
US

V. Phone/Fax

Practice location:
  • Phone: 304-256-4555
  • Fax: 304-256-4715
Mailing address:
  • Phone: 304-719-9701
  • Fax: 304-872-4453

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number22070
License Number StateWV
# 2
Primary TaxonomyN
Taxonomy Code103TS0200X
TaxonomySchool Psychologist
License Number22070
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: