Provider Demographics
NPI:1912997339
Name:BURT MOORE, LINDA KAREN (EDD)
Entity Type:Individual
Prefix:
First Name:LINDA
Middle Name:KAREN
Last Name:BURT MOORE
Suffix:
Gender:F
Credentials:EDD
Other - Prefix:
Other - First Name:LINDA
Other - Middle Name:B
Other - Last Name:MOORE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:EDD
Mailing Address - Street 1:4949 FRANKLIN AVE STE 310
Mailing Address - Street 2:
Mailing Address - City:WACO
Mailing Address - State:TX
Mailing Address - Zip Code:76710-6900
Mailing Address - Country:US
Mailing Address - Phone:254-776-0400
Mailing Address - Fax:254-776-0637
Practice Address - Street 1:4949 FRANKLIN AVE
Practice Address - Street 2:
Practice Address - City:WACO
Practice Address - State:TX
Practice Address - Zip Code:76710-6900
Practice Address - Country:US
Practice Address - Phone:254-776-0400
Practice Address - Fax:254-776-0637
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-26
Last Update Date:2021-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX24997103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX036135401Medicaid
TX119784100OtherSWL PROVIDER NUMBER
TX119210OtherCHIP PROVIDER NUMBER
TX036135401Medicaid
TX119210OtherCHIP PROVIDER NUMBER