Provider Demographics
NPI:1609214436
Name:MOORE, ALTHILIA THERESA (LPC)
Entity type:Individual
Prefix:MS
First Name:ALTHILIA
Middle Name:THERESA
Last Name:MOORE
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17949 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:DUMFRIES
Mailing Address - State:VA
Mailing Address - Zip Code:22026-8000
Mailing Address - Country:US
Mailing Address - Phone:959-200-0189
Mailing Address - Fax:
Practice Address - Street 1:17949 MAIN ST
Practice Address - Street 2:
Practice Address - City:DUMFRIES
Practice Address - State:VA
Practice Address - Zip Code:22026-8000
Practice Address - Country:US
Practice Address - Phone:959-200-0189
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-06-14
Last Update Date:2019-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0701008149101YP2500X
CT003562101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional