Provider Demographics
NPI:1467178020
Name:MOORE, SUSAN LYNETTE
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:LYNETTE
Last Name:MOORE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1324 PRUITT HILL DR APT 705
Mailing Address - Street 2:
Mailing Address - City:NACOGDOCHES
Mailing Address - State:TX
Mailing Address - Zip Code:75961-4634
Mailing Address - Country:US
Mailing Address - Phone:254-855-2805
Mailing Address - Fax:
Practice Address - Street 1:1324 PRUITT HILL DR APT 705
Practice Address - Street 2:
Practice Address - City:NACOGDOCHES
Practice Address - State:TX
Practice Address - Zip Code:75961-4634
Practice Address - Country:US
Practice Address - Phone:254-855-2805
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-10-17
Last Update Date:2022-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX81860101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional