Provider Demographics
NPI:1164151163
Name:MOORE, KEVIN LOWERY (MA, LPCC, LADC)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:LOWERY
Last Name:MOORE
Suffix:
Gender:M
Credentials:MA, LPCC, LADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4463 261ST AVE NW
Mailing Address - Street 2:
Mailing Address - City:ISANTI
Mailing Address - State:MN
Mailing Address - Zip Code:55040-4351
Mailing Address - Country:US
Mailing Address - Phone:176-327-6028
Mailing Address - Fax:
Practice Address - Street 1:4463 261ST AVE NW
Practice Address - Street 2:
Practice Address - City:ISANTI
Practice Address - State:MN
Practice Address - Zip Code:55040-4351
Practice Address - Country:US
Practice Address - Phone:176-327-6028
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-07
Last Update Date:2022-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN303673101YA0400X
MN01764101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty