Provider Demographics
NPI:1881651032
Name:MOORE, CONNY JAN (MS, LPC)
Entity Type:Individual
Prefix:MRS
First Name:CONNY
Middle Name:JAN
Last Name:MOORE
Suffix:
Gender:F
Credentials:MS, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2224 N LANTERN LN
Mailing Address - Street 2:
Mailing Address - City:FLAGSTAFF
Mailing Address - State:AZ
Mailing Address - Zip Code:86001-1133
Mailing Address - Country:US
Mailing Address - Phone:928-774-6824
Mailing Address - Fax:928-556-0504
Practice Address - Street 1:408 N KENDRICK ST
Practice Address - Street 2:FLAGSTAFF CHILD AND FAMILY COUNSELING CENTER SUITE 3
Practice Address - City:FLAGSTAFF
Practice Address - State:AZ
Practice Address - Zip Code:86001-1582
Practice Address - Country:US
Practice Address - Phone:928-774-6364
Practice Address - Fax:928-556-0504
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-04-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ0341101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional