Provider Demographics
NPI:1962800102
Name:MOORE, CECILY RENEE (LPC-MHSP)
Entity type:Individual
Prefix:
First Name:CECILY
Middle Name:RENEE
Last Name:MOORE
Suffix:
Gender:F
Credentials:LPC-MHSP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15 BENT TWIG DR
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:TN
Mailing Address - Zip Code:38305-6477
Mailing Address - Country:US
Mailing Address - Phone:731-394-4555
Mailing Address - Fax:
Practice Address - Street 1:15 BENT TWIG DR
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:TN
Practice Address - Zip Code:38305-6477
Practice Address - Country:US
Practice Address - Phone:731-394-4555
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-12-19
Last Update Date:2023-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
FL222Q00000X
TN4522101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist