Provider Demographics
NPI:1043613094
Name:MOFFITT, LAURIE JO (LCPC)
Entity Type:Individual
Prefix:
First Name:LAURIE
Middle Name:JO
Last Name:MOFFITT
Suffix:
Gender:F
Credentials:LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:111 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:ST CHARLES
Mailing Address - State:IL
Mailing Address - Zip Code:60174-1948
Mailing Address - Country:US
Mailing Address - Phone:630-587-3777
Mailing Address - Fax:
Practice Address - Street 1:111 E MAIN ST
Practice Address - Street 2:
Practice Address - City:ST CHARLES
Practice Address - State:IL
Practice Address - Zip Code:60174-1948
Practice Address - Country:US
Practice Address - Phone:630-587-3777
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-10-06
Last Update Date:2014-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL178.007184101YP2500X
IL180.009400101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional