Healthcare Provider Details

I. General information

NPI: 1245519388
Provider Name (Legal Business Name): LYNN MARIE FAGEN MOORE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/08/2011
Last Update Date: 08/08/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11720 256TH ST
CHISAGO CITY MN
55013-9752
US

IV. Provider business mailing address

11720 256TH ST
CHISAGO CITY MN
55013-9752
US

V. Phone/Fax

Practice location:
  • Phone: 651-257-4159
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number302220
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: