Provider Demographics
NPI:1083945208
Name:MOORE, LADENA CAROL (LPC NCC)
Entity Type:Individual
Prefix:
First Name:LADENA
Middle Name:CAROL
Last Name:MOORE
Suffix:
Gender:F
Credentials:LPC NCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 912
Mailing Address - Street 2:
Mailing Address - City:PRYOR
Mailing Address - State:OK
Mailing Address - Zip Code:74362-0912
Mailing Address - Country:US
Mailing Address - Phone:918-825-4115
Mailing Address - Fax:918-825-6612
Practice Address - Street 1:212 S E 1ST
Practice Address - Street 2:
Practice Address - City:PRYOR
Practice Address - State:OK
Practice Address - Zip Code:74361
Practice Address - Country:US
Practice Address - Phone:918-825-4115
Practice Address - Fax:918-825-6612
Is Sole Proprietor?:No
Enumeration Date:2010-01-28
Last Update Date:2010-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK3702101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100732380FMedicaid