Provider Demographics
NPI:1578159836
Name:MOORE, IMAGINE MYJOY (LPC-ASSOCIATE)
Entity Type:Individual
Prefix:MISS
First Name:IMAGINE
Middle Name:MYJOY
Last Name:MOORE
Suffix:
Gender:F
Credentials:LPC-ASSOCIATE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:115 KELLY DR.
Mailing Address - Street 2:
Mailing Address - City:WAXAHACHIE
Mailing Address - State:TX
Mailing Address - Zip Code:75167
Mailing Address - Country:US
Mailing Address - Phone:972-765-1204
Mailing Address - Fax:
Practice Address - Street 1:716 W. MAIN STREET
Practice Address - Street 2:
Practice Address - City:WAXAHACHIE
Practice Address - State:TX
Practice Address - Zip Code:75165
Practice Address - Country:US
Practice Address - Phone:972-765-1204
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-12-21
Last Update Date:2022-07-01
Deactivation Date:2022-05-13
Deactivation Code:
Reactivation Date:2022-06-27
Provider Licenses
StateLicense IDTaxonomies
LAPLC8927101YP2500X
TX88683101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional