Healthcare Provider Details

I. General information

NPI: 1649604885
Provider Name (Legal Business Name): HEATHER RENEE MOORE MA, LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: HEATHER RENEE JONES

II. Dates (important events)

Enumeration Date: 08/23/2013
Last Update Date: 05/26/2020
Certification Date: 05/26/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

550 S PEORIA AVE
TULSA OK
74120-3820
US

IV. Provider business mailing address

550 S PEORIA AVE
TULSA OK
74120-3820
US

V. Phone/Fax

Practice location:
  • Phone: 918-588-1900
  • Fax: 918-382-1285
Mailing address:
  • Phone: 918-588-1900
  • Fax: 918-382-1285

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number5751
License Number StateOK
# 2
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number5751
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: