Provider Demographics
NPI:1467178020
Name:MOORE, SUSAN LYNETTE
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:LYNETTE
Last Name:MOORE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3524 NE STALLINGS DR
Mailing Address - Street 2:
Mailing Address - City:NACOGDOCHES
Mailing Address - State:TX
Mailing Address - Zip Code:75965-8728
Mailing Address - Country:US
Mailing Address - Phone:936-560-6855
Mailing Address - Fax:936-564-5232
Practice Address - Street 1:3524 NE STALLINGS DR
Practice Address - Street 2:
Practice Address - City:NACOGDOCHES
Practice Address - State:TX
Practice Address - Zip Code:75965-8728
Practice Address - Country:US
Practice Address - Phone:936-560-6855
Practice Address - Fax:936-564-5232
Is Sole Proprietor?:Yes
Enumeration Date:2022-10-17
Last Update Date:2024-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX81860101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional