Healthcare Provider Details

I. General information

NPI: 1073152187
Provider Name (Legal Business Name): JOEY LEE MOORE LCPC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/06/2020
Last Update Date: 01/06/2020
Certification Date: 01/06/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1305 WYOMING ST
MISSOULA MT
59801-1725
US

IV. Provider business mailing address

1321 WYOMING ST
MISSOULA MT
59801-1725
US

V. Phone/Fax

Practice location:
  • Phone: 406-532-9770
  • Fax: 406-541-3034
Mailing address:
  • Phone: 406-532-8400
  • Fax: 406-224-4402

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number38912
License Number StateMT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: