=====================================================
General NPI Number Information
=====================================================
NPI Number | 1811534639
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MOORE MENTAL HEALTH COUNSELING SERVICES, PLLC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/01/2019
-----------------------------------------------------
Last Update Date | 12/01/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 124 E 40TH ST RM 404
-----------------------------------------------------
City | NEW YORK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10016-1764
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 646-801-5316
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 339
-----------------------------------------------------
City | BRONX
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10463-0339
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 646-801-5316
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | SOBHUZA MOORE
-----------------------------------------------------
Credential | MA, LMHC, NCC
-----------------------------------------------------
Telephone | 646-801-5316
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 261QM0801X
-----------------------------------------------------
Taxonomy Name | Mental Health Clinic/Center (Including Community Mental Health Center)
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 261QM0850X
-----------------------------------------------------
Taxonomy Name | Adult Mental Health Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------