Provider Demographics
NPI:1801939533
Name:MOORE JOHNSON, MONTY L (LCPC)
Entity type:Individual
Prefix:
First Name:MONTY
Middle Name:L
Last Name:MOORE JOHNSON
Suffix:
Gender:F
Credentials:LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 44689
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83711-0689
Mailing Address - Country:US
Mailing Address - Phone:208-376-0979
Mailing Address - Fax:208-378-1089
Practice Address - Street 1:6540 W EMERALD ST
Practice Address - Street 2:SUITE 100
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83704-8782
Practice Address - Country:US
Practice Address - Phone:208-376-0979
Practice Address - Fax:208-378-1089
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLCPC-209101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDQ6371OtherBLUE CROSS OF IDAHO
ID000010145850OtherREGENCE BLUE SHIELD OF ID