Provider Demographics
NPI:1891079794
Name:MOE, KRISTA (PHD)
Entity Type:Individual
Prefix:
First Name:KRISTA
Middle Name:
Last Name:MOE
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2700 STANLEY GAULT PKWY STE 129
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40223-5176
Mailing Address - Country:US
Mailing Address - Phone:502-253-4966
Mailing Address - Fax:502-489-5751
Practice Address - Street 1:1760 NICHOLASVILLE RD
Practice Address - Street 2:SUITE 301
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40503-1471
Practice Address - Country:US
Practice Address - Phone:859-260-5527
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-10-11
Last Update Date:2020-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY1750103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KYP01458492OtherRR MEDICARE
KY7100315990Medicaid
KY7100315990Medicaid