Provider Demographics
NPI:1962773390
Name:MOYERS, TRESA MCKOIN (CAC)
Entity type:Individual
Prefix:MRS
First Name:TRESA
Middle Name:MCKOIN
Last Name:MOYERS
Suffix:
Gender:F
Credentials:CAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15247 LAKESHORE DR
Mailing Address - Street 2:
Mailing Address - City:BONITA
Mailing Address - State:LA
Mailing Address - Zip Code:71223-9670
Mailing Address - Country:US
Mailing Address - Phone:318-823-3077
Mailing Address - Fax:318-823-3077
Practice Address - Street 1:320 S FRANKLIN ST
Practice Address - Street 2:
Practice Address - City:BASTROP
Practice Address - State:LA
Practice Address - Zip Code:71220-4539
Practice Address - Country:US
Practice Address - Phone:318-556-7040
Practice Address - Fax:318-283-0875
Is Sole Proprietor?:No
Enumeration Date:2012-01-17
Last Update Date:2012-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA1324101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)