Provider Demographics
NPI:1093588683
Name:MOERY, KRISTIN JILL (LADC-MH CANDIDATE)
Entity type:Individual
Prefix:MS
First Name:KRISTIN
Middle Name:JILL
Last Name:MOERY
Suffix:
Gender:F
Credentials:LADC-MH CANDIDATE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16 COUNTRY CLUB DR
Mailing Address - Street 2:
Mailing Address - City:HENNESSEY
Mailing Address - State:OK
Mailing Address - Zip Code:73742-9799
Mailing Address - Country:US
Mailing Address - Phone:405-853-1184
Mailing Address - Fax:
Practice Address - Street 1:300 W CHEROKEE AVE STE 102
Practice Address - Street 2:
Practice Address - City:ENID
Practice Address - State:OK
Practice Address - Zip Code:73701-5600
Practice Address - Country:US
Practice Address - Phone:580-340-7235
Practice Address - Fax:580-324-6324
Is Sole Proprietor?:Yes
Enumeration Date:2023-11-06
Last Update Date:2023-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKCANDIDATE101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health