Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 103TA0400X | Addiction Psychologist (Substance Use Disorder) | LDC0000001260 | TN |
N | 103TC1900X | Counseling Psychologist |
NPI | 1255736153 |
---|---|
Provider Name | Sonya Glyn Moore |
First Address | Morristown, TN 37814-4617 |
Second Address | Morristown, TN 37814-4617 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 04/11/2014 |
Last Update Date | 11/06/2019 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
Q028453 | (05) | TN |