Provider Demographics
NPI:1255736153
Name:MOORE, SONYA GLYN (MS , LADAC II)
Entity type:Individual
Prefix:
First Name:SONYA
Middle Name:GLYN
Last Name:MOORE
Suffix:
Gender:F
Credentials:MS , LADAC II
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4845 W ANDREW JOHNSON HWY
Mailing Address - Street 2:
Mailing Address - City:MORRISTOWN
Mailing Address - State:TN
Mailing Address - Zip Code:37814-1023
Mailing Address - Country:US
Mailing Address - Phone:828-335-2310
Mailing Address - Fax:423-266-5101
Practice Address - Street 1:400 W 1ST NORTH ST STE D
Practice Address - Street 2:
Practice Address - City:MORRISTOWN
Practice Address - State:TN
Practice Address - Zip Code:37814-4617
Practice Address - Country:US
Practice Address - Phone:828-335-2310
Practice Address - Fax:423-266-5101
Is Sole Proprietor?:Yes
Enumeration Date:2014-11-04
Last Update Date:2025-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YA0400X, 103TC1900X
TNLDC0000001260103TA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TA0400XBehavioral Health & Social Service ProvidersPsychologistAddiction (Substance Use Disorder)
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNQ028453Medicaid