Provider Demographics
NPI:1154167955
Name:MOON, LORI JEAN (LCDC)
Entity type:Individual
Prefix:
First Name:LORI
Middle Name:JEAN
Last Name:MOON
Suffix:
Gender:F
Credentials:LCDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3971 FM 1249 E LOT 12
Mailing Address - Street 2:
Mailing Address - City:KILGORE
Mailing Address - State:TX
Mailing Address - Zip Code:75662-8469
Mailing Address - Country:US
Mailing Address - Phone:903-917-1798
Mailing Address - Fax:
Practice Address - Street 1:3971 FM 1249 E
Practice Address - Street 2:
Practice Address - City:KILGORE
Practice Address - State:TX
Practice Address - Zip Code:75662-8468
Practice Address - Country:US
Practice Address - Phone:903-917-1798
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-07-02
Last Update Date:2024-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX16764101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)