Provider Demographics
NPI:1669723326
Name:MOORE, ELIZABETH ANN (PHD, LCSW)
Entity type:Individual
Prefix:DR
First Name:ELIZABETH
Middle Name:ANN
Last Name:MOORE
Suffix:
Gender:F
Credentials:PHD, LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2084 OLD TAYLOR RD
Mailing Address - Street 2:SUITE 107
Mailing Address - City:OXFORD
Mailing Address - State:MS
Mailing Address - Zip Code:38655-5189
Mailing Address - Country:US
Mailing Address - Phone:662-701-9851
Mailing Address - Fax:
Practice Address - Street 1:2084 OLD TAYLOR RD
Practice Address - Street 2:SUITE 107
Practice Address - City:OXFORD
Practice Address - State:MS
Practice Address - Zip Code:38655-5189
Practice Address - Country:US
Practice Address - Phone:662-701-9851
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-09-20
Last Update Date:2015-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSC8117101YM0800X
CO991428174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No174400000XOther Service ProvidersSpecialist