Healthcare Provider Details

I. General information

NPI: 1467178020
Provider Name (Legal Business Name): SUSAN LYNETTE MOORE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/17/2022
Last Update Date: 08/18/2026
Certification Date: 08/18/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

901 S HEWITT DR UNIT 36
HEWITT TX
76643-8003
US

IV. Provider business mailing address

901 S HEWITT DR UNIT 36
HEWITT TX
76643-8003
US

V. Phone/Fax

Practice location:
  • Phone: 254-644-8883
  • Fax:
Mailing address:
  • Phone: 254-644-8883
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number81860
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: