Provider Demographics
NPI:1750152203
Name:MOORE, AMANDA (LPC)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:
Last Name:MOORE
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:AMANDA
Other - Middle Name:MOORE
Other - Last Name:SASSER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LPC
Mailing Address - Street 1:2195 LOGAN DR
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83401-4404
Mailing Address - Country:US
Mailing Address - Phone:208-357-8909
Mailing Address - Fax:
Practice Address - Street 1:855 N CAPITAL AVE STE 1
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83402-3405
Practice Address - Country:US
Practice Address - Phone:208-552-0855
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-01-12
Last Update Date:2024-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID10116101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty