Healthcare Provider Details

I. General information

NPI: 1629200340
Provider Name (Legal Business Name): OLGA V MOFFETT CIDDT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/13/2009
Last Update Date: 09/08/2026
Certification Date: 09/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

688 ANTELOPE GAP RD
WHEATLAND WY
82201-8810
US

IV. Provider business mailing address

14 PLANTATION DR
HATTIESBURG MS
39402-6116
US

V. Phone/Fax

Practice location:
  • Phone: 307-331-7869
  • Fax: 307-316-0378
Mailing address:
  • Phone: 601-705-1901
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number94443
License Number StateMS
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberBBH-LCPC-LIC-81088
License Number StateMT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: