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General NPI Number Information
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NPI Number | 1285266858
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Entity Type | Individual
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Provider Name | STEFANIE MOORE LPC
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Gender | Female
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Dates
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Enumeration Date | 02/11/2020
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Last Update Date | 11/10/2021
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Provider Practice Location Address
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Address Line | 100 LLOYD AVE STE E
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City | TYRONE
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State | GA
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Zip | 30290-2157
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Country | US
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Telephone | 470-215-6101
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Fax |
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Provider Business Mailing Address
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Address Line | 147 HUNTERIAN PL
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City | NEWNAN
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State | GA
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Zip | 30265-5619
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Country | US
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Telephone | 770-328-0490
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YP2500X
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Taxonomy Name | Professional Counselor
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License Number | LPC011376
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License Number State | GA
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