Provider Demographics
NPI:1770067498
Name:MOORE, JUANESE (LPC)
Entity type:Individual
Prefix:
First Name:JUANESE
Middle Name:
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 1:375 ROCKBRIDGE RD NW STE 172-350
Mailing Address - Street 2:
Mailing Address - City:LILBURN
Mailing Address - State:GA
Mailing Address - Zip Code:30047-8225
Mailing Address - Country:US
Mailing Address - Phone:770-609-7288
Mailing Address - Fax:
Practice Address - Street 1:4500 HUGH HOWELL RD STE 620D
Practice Address - Street 2:
Practice Address - City:TUCKER
Practice Address - State:GA
Practice Address - Zip Code:30084-4720
Practice Address - Country:US
Practice Address - Phone:770-609-7288
Practice Address - Fax:470-777-2790
Is Sole Proprietor?:Yes
Enumeration Date:2018-09-18
Last Update Date:2021-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALPC010471101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health