Provider Demographics
NPI:1730375486
Name:MOORE-PETERSON, CHARLENE ANNETTE (EDD, LPC)
Entity type:Individual
Prefix:DR
First Name:CHARLENE
Middle Name:ANNETTE
Last Name:MOORE-PETERSON
Suffix:
Gender:F
Credentials:EDD, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6454 BRIDGEWOOD RD
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29206-2126
Mailing Address - Country:US
Mailing Address - Phone:803-500-5065
Mailing Address - Fax:803-500-5065
Practice Address - Street 1:6454 BRIDGEWOOD RD
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29206-2126
Practice Address - Country:US
Practice Address - Phone:803-500-5065
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-09-17
Last Update Date:2023-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC6666101YM0800X
GALPC011406101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC421504Medicaid
SC421504Medicaid