Provider Demographics
NPI:1316155633
Name:MOORE, LAFACIAL WILSON (PHD)
Entity type:Individual
Prefix:DR
First Name:LAFACIAL
Middle Name:WILSON
Last Name:MOORE
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:DR
Other - First Name:LAFACIAL
Other - Middle Name:YVETTE
Other - Last Name:WILSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PHD
Mailing Address - Street 1:924 MONTCLAIR RD
Mailing Address - Street 2:SUITE 106
Mailing Address - City:BIRMINGHAM
Mailing Address - State:AL
Mailing Address - Zip Code:35213-1211
Mailing Address - Country:US
Mailing Address - Phone:205-218-9398
Mailing Address - Fax:
Practice Address - Street 1:924 MONTCLAIR RD
Practice Address - Street 2:SUITE 106
Practice Address - City:BIRMINGHAM
Practice Address - State:AL
Practice Address - Zip Code:35213-1211
Practice Address - Country:US
Practice Address - Phone:205-218-9398
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-18
Last Update Date:2017-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL2364101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional