Healthcare Provider Details

I. General information

NPI: 1326705989
Provider Name (Legal Business Name): KIMBERLY ANN MOYER LCPC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/18/2021
Last Update Date: 11/18/2021
Certification Date: 10/05/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7330 W COLLEGE DR
PALOS HEIGHTS IL
60463-1157
US

IV. Provider business mailing address

10835 S WASHTENAW AVE
CHICAGO IL
60655-1730
US

V. Phone/Fax

Practice location:
  • Phone: 708-316-1377
  • Fax:
Mailing address:
  • Phone: 773-386-4316
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number180004373
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: