Provider Demographics
NPI:1558043687
Name:MOORE, AUDREY ELAINE (LAC)
Entity type:Individual
Prefix:
First Name:AUDREY
Middle Name:ELAINE
Last Name:MOORE
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:AUDREY
Other - Middle Name:
Other - Last Name:STEWART
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:5700 MARKET ST APT 2086
Mailing Address - Street 2:
Mailing Address - City:PRESCOTT VALLEY
Mailing Address - State:AZ
Mailing Address - Zip Code:86314-6517
Mailing Address - Country:US
Mailing Address - Phone:208-505-8933
Mailing Address - Fax:
Practice Address - Street 1:702 W HILLSIDE AVE
Practice Address - Street 2:
Practice Address - City:PRESCOTT
Practice Address - State:AZ
Practice Address - Zip Code:86301-1913
Practice Address - Country:US
Practice Address - Phone:855-746-3633
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-08-07
Last Update Date:2024-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ22964101YM0800X
106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health