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General NPI Number Information
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NPI Number | 1558043687
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Entity Type | Individual
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Provider Name | AUDREY ELAINE MOORE LAC
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Gender | Female
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Dates
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Enumeration Date | 08/07/2023
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Last Update Date | 10/16/2024
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Provider Practice Location Address
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Address Line | 702 W HILLSIDE AVE
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City | PRESCOTT
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State | AZ
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Zip | 86301-1913
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Country | US
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Telephone | 855-746-3633
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Fax |
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Provider Business Mailing Address
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Address Line | 5700 MARKET ST APT 2086
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City | PRESCOTT VALLEY
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State | AZ
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Zip | 86314-6517
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Country | US
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Telephone | 208-505-8933
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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 | 22964
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License Number State | AZ
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