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General NPI Number Information
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NPI Number | 1104578830
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Entity Type | Individual
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Provider Name | MARY KAY MOORE LPC-A
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Gender | Female
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Dates
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Enumeration Date | 01/24/2022
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Last Update Date | 01/24/2022
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Provider Practice Location Address
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Address Line | 1504 WOOD ACRE LN
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City | AUSTIN
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State | TX
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Zip | 78733-2157
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Country | US
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Telephone | 512-636-0888
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Fax |
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Provider Business Mailing Address
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Address Line | 1500 VILLAGE WEST DR # 69
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City | AUSTIN
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State | TX
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Zip | 78733-1977
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Country | US
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Telephone | 512-636-0888
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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 | 101YM0800X
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Taxonomy Name | Mental Health Counselor
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License Number | 87741
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License Number State | TX
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