Provider Demographics
NPI:1902656606
Name:MOORE, SHEA BRADLEY (LPC-MHSP)
Entity Type:Individual
Prefix:
First Name:SHEA
Middle Name:BRADLEY
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 1:119 JUPITER DR
Mailing Address - Street 2:
Mailing Address - City:ASHLAND CITY
Mailing Address - State:TN
Mailing Address - Zip Code:37015-4904
Mailing Address - Country:US
Mailing Address - Phone:615-440-7116
Mailing Address - Fax:
Practice Address - Street 1:1 VANTAGE WAY STE E130
Practice Address - Street 2:
Practice Address - City:NASHVILLE
Practice Address - State:TN
Practice Address - Zip Code:37228-1591
Practice Address - Country:US
Practice Address - Phone:615-669-0179
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-03-25
Last Update Date:2024-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN7049101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health