Provider Demographics
NPI:1619464062
Name:MOFFETT, MEAGAN (LBA)
Entity Type:Individual
Prefix:MS
First Name:MEAGAN
Middle Name:
Last Name:MOFFETT
Suffix:
Gender:F
Credentials:LBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:173 MOFFETT RD
Mailing Address - Street 2:
Mailing Address - City:JENA
Mailing Address - State:LA
Mailing Address - Zip Code:71342-5747
Mailing Address - Country:US
Mailing Address - Phone:318-316-5077
Mailing Address - Fax:318-322-6500
Practice Address - Street 1:1103 HUDSON LN
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:LA
Practice Address - Zip Code:71201-6035
Practice Address - Country:US
Practice Address - Phone:318-322-6500
Practice Address - Fax:318-322-5118
Is Sole Proprietor?:No
Enumeration Date:2018-04-20
Last Update Date:2018-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAL-284103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst