Provider Demographics
NPI:1902840960
Name:MOORE, CONNIE JUNG (PHD, LPC)
Entity Type:Individual
Prefix:
First Name:CONNIE
Middle Name:JUNG
Last Name:MOORE
Suffix:
Gender:F
Credentials:PHD, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12352 SPRING CIR
Mailing Address - Street 2:
Mailing Address - City:GUTHRIE
Mailing Address - State:OK
Mailing Address - Zip Code:73044-9772
Mailing Address - Country:US
Mailing Address - Phone:405-473-3453
Mailing Address - Fax:
Practice Address - Street 1:12352 SPRING CIR
Practice Address - Street 2:
Practice Address - City:GUTHRIE
Practice Address - State:OK
Practice Address - Zip Code:73044-9772
Practice Address - Country:US
Practice Address - Phone:405-473-3453
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-16
Last Update Date:2024-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK3379101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional