Basic Information
Provider Information | |||||||||
NPI: | 1972059046 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | MOORER | ||||||||
FirstName: | LINDA | ||||||||
MiddleName: |   | ||||||||
NamePrefix: | MS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | LCSW | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | MOORER-FOGLE | ||||||||
OtherFirstName: | LINDA | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: | MS. | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | LCSW | ||||||||
OtherLastNameType: | 2 | ||||||||
Mailing Information | |||||||||
Address1: | 3483 RIVER MILL LN | ||||||||
Address2: |   | ||||||||
City: | ELLENWOOD | ||||||||
State: | GA | ||||||||
PostalCode: | 302941359 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4042410461 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 175 GWINNETT DR | ||||||||
Address2: |   | ||||||||
City: | LAWRENCEVILLE | ||||||||
State: | GA | ||||||||
PostalCode: | 300468444 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6782092394 | ||||||||
FaxNumber: | 6782126343 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/29/2016 | ||||||||
LastUpdateDate: | 08/29/2016 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | 000967 | GA | Y |   | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.