Provider Demographics
NPI:1538287511
Name:MOORE, ELISSA DAWN (MS LMFT)
Entity Type:Individual
Prefix:MRS
First Name:ELISSA
Middle Name:DAWN
Last Name:MOORE
Suffix:
Gender:F
Credentials:MS LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:555 N WOODLAWN ST STE 102
Mailing Address - Street 2:
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67208-3671
Mailing Address - Country:US
Mailing Address - Phone:316-652-2590
Mailing Address - Fax:316-652-2595
Practice Address - Street 1:555 N WOODLAWN ST STE 102
Practice Address - Street 2:
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67208-3671
Practice Address - Country:US
Practice Address - Phone:316-652-2590
Practice Address - Fax:316-652-2595
Is Sole Proprietor?:No
Enumeration Date:2007-03-27
Last Update Date:2010-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS878106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS100098090AMedicaid