Provider Demographics
NPI:1114770989
Name:FENWOOD LICENSED PROFESSIONAL CLINICAL COUNSELOR, PC
Entity Type:Organization
Organization Name:FENWOOD LICENSED PROFESSIONAL CLINICAL COUNSELOR, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/CEO
Authorized Official - Prefix:
Authorized Official - First Name:LINDSEY
Authorized Official - Middle Name:
Authorized Official - Last Name:BUCK-MOYER
Authorized Official - Suffix:
Authorized Official - Credentials:LPCC
Authorized Official - Phone:916-251-9474
Mailing Address - Street 1:8690 SIERRA COLLEGE BLVD STE 160-140
Mailing Address - Street 2:
Mailing Address - City:ROSEVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95661-5961
Mailing Address - Country:US
Mailing Address - Phone:916-251-9474
Mailing Address - Fax:
Practice Address - Street 1:5800 STANFORD RANCH RD STE 610
Practice Address - Street 2:
Practice Address - City:ROCKLIN
Practice Address - State:CA
Practice Address - Zip Code:95765-4387
Practice Address - Country:US
Practice Address - Phone:916-251-9474
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-04-10
Last Update Date:2024-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)