Healthcare Provider Details

I. General information

NPI: 1477436301
Provider Name (Legal Business Name): DEVON GRACE ANN MOORE LMHC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/29/2025
Last Update Date: 07/29/2025
Certification Date: 07/25/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18 THOROUGHBRED TRL
LAMY NM
87540-9009
US

IV. Provider business mailing address

18 THOROUGHBRED TRL
LAMY NM
87540-9009
US

V. Phone/Fax

Practice location:
  • Phone: 575-779-4048
  • Fax:
Mailing address:
  • Phone: 575-779-4048
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberCMH0197091
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: