Provider Demographics
NPI:1821820101
Name:MOORE, LISA RENE (T-LMFT)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:RENE
Last Name:MOORE
Suffix:
Gender:F
Credentials:T-LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13122 HERITAGE DR
Mailing Address - Street 2:
Mailing Address - City:BONNER SPRINGS
Mailing Address - State:KS
Mailing Address - Zip Code:66012-9602
Mailing Address - Country:US
Mailing Address - Phone:785-424-3582
Mailing Address - Fax:
Practice Address - Street 1:11400 JOHNSON DR
Practice Address - Street 2:
Practice Address - City:SHAWNEE
Practice Address - State:KS
Practice Address - Zip Code:66203-2642
Practice Address - Country:US
Practice Address - Phone:785-272-0778
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-08-15
Last Update Date:2024-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist