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General NPI Number Information
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NPI Number | 1063360758
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Entity Type | Individual
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Provider Name | MELANIE RENEE MOORE
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Gender | Female
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Dates
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Enumeration Date | 03/18/2026
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Last Update Date | 03/18/2026
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Provider Practice Location Address
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Address Line | 396 YELLOWSTONE AVE
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City | POCATELLO
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State | ID
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Zip | 83201-4572
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Country | US
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Telephone | 385-985-6354
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Fax |
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Provider Business Mailing Address
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Address Line | 561 RAVEN WAY
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City | CHUBBUCK
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State | ID
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Zip | 83202-1971
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Country | US
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Telephone | 385-985-6354
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YP2500X
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Taxonomy Name | Professional Counselor
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License Number | 4671296
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License Number State | ID
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