Healthcare Provider Details

I. General information

NPI: 1083518419
Provider Name (Legal Business Name): KATRINA MIXON MOORE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/07/2026
Last Update Date: 10/07/2026
Certification Date: 10/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

153 POPLAR GREEN LN
HARVEST AL
35749-8893
US

IV. Provider business mailing address

153 POPLAR GREEN LN
HARVEST AL
35749-8893
US

V. Phone/Fax

Practice location:
  • Phone: 256-652-5187
  • Fax:
Mailing address:
  • Phone: 256-652-5187
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License NumberALC06096
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: