Healthcare Provider Details

I. General information

NPI: 1932279940
Provider Name (Legal Business Name): CASSANDRA LOU MOE LADC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/08/2006
Last Update Date: 09/02/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1321 13TH ST N
ST CLOUD MN
56303-2614
US

IV. Provider business mailing address

1321 13TH ST N
ST CLOUD MN
56303-2614
US

V. Phone/Fax

Practice location:
  • Phone: 320-292-5010
  • Fax: 320-203-1855
Mailing address:
  • Phone: 320-292-5010
  • Fax: 320-203-1855

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: