Healthcare Provider Details

I. General information

NPI: 1700611530
Provider Name (Legal Business Name): LIAAMIA MOORE LMHC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/03/2024
Last Update Date: 09/03/2024
Certification Date: 09/03/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1800 WESLEY RD
AUBURN IN
46706-3653
US

IV. Provider business mailing address

220 S MAIN ST
KENDALLVILLE IN
46755-1718
US

V. Phone/Fax

Practice location:
  • Phone: 260-925-2453
  • Fax:
Mailing address:
  • Phone: 260-347-2453
  • Fax: 260-347-5649

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number39004988A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: