Provider Demographics
NPI:1710769849
Name:SELLS-MOORE, LISA L (TCM)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:L
Last Name:SELLS-MOORE
Suffix:
Gender:F
Credentials:TCM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:120 N KNOX
Mailing Address - Street 2:#398
Mailing Address - City:FT KNOX
Mailing Address - State:KY
Mailing Address - Zip Code:40121
Mailing Address - Country:US
Mailing Address - Phone:469-401-4222
Mailing Address - Fax:
Practice Address - Street 1:653 WINDBROOK DR
Practice Address - Street 2:
Practice Address - City:ELIZABETHTOWN
Practice Address - State:KY
Practice Address - Zip Code:42701-6827
Practice Address - Country:US
Practice Address - Phone:502-500-4452
Practice Address - Fax:502-873-0020
Is Sole Proprietor?:No
Enumeration Date:2023-10-13
Last Update Date:2023-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator