Provider Demographics
NPI:1285044958
Name:MOORE, REGINA J (MED, LPC, NCC)
Entity Type:Individual
Prefix:
First Name:REGINA
Middle Name:J
Last Name:MOORE
Suffix:
Gender:F
Credentials:MED, LPC, NCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3584 COURTLAND DR
Mailing Address - Street 2:
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70814-2810
Mailing Address - Country:US
Mailing Address - Phone:225-302-2123
Mailing Address - Fax:
Practice Address - Street 1:12097 OLD HAMMOND HWY STE I4
Practice Address - Street 2:
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70816
Practice Address - Country:US
Practice Address - Phone:225-246-8816
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-05-05
Last Update Date:2018-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA4401101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA101YP2500XMedicaid