Provider Demographics
NPI:1568823052
Name:MOORE, JULIA
Entity type:Individual
Prefix:
First Name:JULIA
Middle Name:
Last Name:MOORE
Suffix:
Gender:F
Credentials:
Other - Prefix:MRS
Other - First Name:JULIA
Other - Middle Name:
Other - Last Name:MOORE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:2620 CENTENARY BLVD
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71104-3356
Mailing Address - Country:US
Mailing Address - Phone:318-518-9197
Mailing Address - Fax:
Practice Address - Street 1:5031 DEDMAN DR
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71107-2821
Practice Address - Country:US
Practice Address - Phone:318-518-9197
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-03-11
Last Update Date:2024-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X, 171M00000X
LAPLC10008101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No171M00000XOther Service ProvidersCase Manager/Care Coordinator