Provider Demographics
NPI:1336537596
Name:MOORE, STACY
Entity type:Individual
Prefix:
First Name:STACY
Middle Name:
Last Name:MOORE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2501 PITTSTON RD
Mailing Address - Street 2:
Mailing Address - City:FREDERICKSBURG
Mailing Address - State:VA
Mailing Address - Zip Code:22408-0261
Mailing Address - Country:US
Mailing Address - Phone:540-361-4742
Mailing Address - Fax:540-373-1464
Practice Address - Street 1:2501 PITTSTON RD
Practice Address - Street 2:
Practice Address - City:FREDERICKSBURG
Practice Address - State:VA
Practice Address - Zip Code:22408-0261
Practice Address - Country:US
Practice Address - Phone:540-361-4742
Practice Address - Fax:540-373-1464
Is Sole Proprietor?:No
Enumeration Date:2014-12-22
Last Update Date:2014-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker