=====================================================
General NPI Number Information
=====================================================
NPI Number | 1669723326
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ELIZABETH ANN MOORE PHD, LCSW
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/20/2012
-----------------------------------------------------
Last Update Date | 06/09/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2084 OLD TAYLOR RD SUITE 107
-----------------------------------------------------
City | OXFORD
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 38655-5189
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 662-701-9851
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2084 OLD TAYLOR RD SUITE 107
-----------------------------------------------------
City | OXFORD
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 38655-5189
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 662-701-9851
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number | C8117
-----------------------------------------------------
License Number State | MS
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 174400000X
-----------------------------------------------------
Taxonomy Name | Specialist
-----------------------------------------------------
License Number | 991428
-----------------------------------------------------
License Number State | CO
-----------------------------------------------------