Provider Demographics
NPI:1902459480
Name:MOORE, COOPER THOMAS (LMHC)
Entity Type:Individual
Prefix:MR
First Name:COOPER
Middle Name:THOMAS
Last Name:MOORE
Suffix:
Gender:M
Credentials:LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1301 PLANTATION ISLAND DR S STE 202A
Mailing Address - Street 2:
Mailing Address - City:ST AUGUSTINE
Mailing Address - State:FL
Mailing Address - Zip Code:32080-3111
Mailing Address - Country:US
Mailing Address - Phone:904-318-8500
Mailing Address - Fax:
Practice Address - Street 1:1301 PLANTATION ISLAND DR S STE 202A
Practice Address - Street 2:
Practice Address - City:ST AUGUSTINE
Practice Address - State:FL
Practice Address - Zip Code:32080-3111
Practice Address - Country:US
Practice Address - Phone:904-318-8500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-23
Last Update Date:2023-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH18603101YM0800X
FL17529101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health