Provider Demographics
NPI:1184853939
Name:MOORE, KATHLEEN J WALSH (LPC)
Entity type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:J WALSH
Last Name:MOORE
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:805 DOUGLAS CHURCH ROAD
Mailing Address - Street 2:
Mailing Address - City:FARMVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:23901
Mailing Address - Country:US
Mailing Address - Phone:804-244-1125
Mailing Address - Fax:434-392-9221
Practice Address - Street 1:2000 REGENCY PKWY STE 255
Practice Address - Street 2:
Practice Address - City:CARY
Practice Address - State:NC
Practice Address - Zip Code:27518-8511
Practice Address - Country:US
Practice Address - Phone:704-360-3637
Practice Address - Fax:980-939-8769
Is Sole Proprietor?:No
Enumeration Date:2009-07-14
Last Update Date:2024-01-24
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
VA0710101961101YA0400X
VA0701003192103TC0700X
NC11771101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1528091063Medicaid