Provider Demographics
NPI:1104523323
Name:MOORE, BERNADETTE ANN (LPC)
Entity type:Individual
Prefix:MRS
First Name:BERNADETTE
Middle Name:ANN
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:PO BOX 178
Mailing Address - Street 2:
Mailing Address - City:HARDWICK
Mailing Address - State:GA
Mailing Address - Zip Code:31034-0178
Mailing Address - Country:US
Mailing Address - Phone:478-363-6408
Mailing Address - Fax:
Practice Address - Street 1:611 N WAYNE ST
Practice Address - Street 2:
Practice Address - City:MILLEDGEVILLE
Practice Address - State:GA
Practice Address - Zip Code:31061-2834
Practice Address - Country:US
Practice Address - Phone:478-254-0481
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-02-08
Last Update Date:2023-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA013476101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty