Healthcare Provider Details

I. General information

NPI: 1326789405
Provider Name (Legal Business Name): HEATHER MOEN LAC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/05/2022
Last Update Date: 04/07/2026
Certification Date: 04/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2424 32ND AVE S STE 103
GRAND FORKS ND
58201-6509
US

IV. Provider business mailing address

8444 N 90TH ST STE 100
SCOTTSDALE AZ
85258-4437
US

V. Phone/Fax

Practice location:
  • Phone: 602-248-8886
  • Fax: 602-854-0504
Mailing address:
  • Phone: 602-248-8886
  • Fax: 602-854-0504

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number1927
License Number StateND

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: