Provider Demographics
NPI:1093561987
Name:LISA J MOORE LLC
Entity type:Organization
Organization Name:LISA J MOORE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ELISABETH
Authorized Official - Middle Name:J
Authorized Official - Last Name:TUDOR
Authorized Official - Suffix:
Authorized Official - Credentials:LMHC
Authorized Official - Phone:904-269-2931
Mailing Address - Street 1:1409 KINGSLEY AVE STE 9D
Mailing Address - Street 2:
Mailing Address - City:ORANGE PARK
Mailing Address - State:FL
Mailing Address - Zip Code:32073-4580
Mailing Address - Country:US
Mailing Address - Phone:904-571-8701
Mailing Address - Fax:904-571-8701
Practice Address - Street 1:1409 KINGSLEY AVE STE 9D
Practice Address - Street 2:
Practice Address - City:ORANGE PARK
Practice Address - State:FL
Practice Address - Zip Code:32073-4580
Practice Address - Country:US
Practice Address - Phone:904-571-8701
Practice Address - Fax:904-571-8701
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-04-30
Last Update Date:2024-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty