=====================================================
General NPI Number Information
=====================================================
NPI Number | 1730401712
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | NEECIE MOORE PHD, LPC, LMFT
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/18/2010
-----------------------------------------------------
Last Update Date | 02/18/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2435 E HEBRON PKWY
-----------------------------------------------------
City | CARROLLTON
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75010-4427
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 214-739-6644
-----------------------------------------------------
Fax | 214-231-2957
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4516 LOVERS LN SUITE 179
-----------------------------------------------------
City | DALLAS
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75225-6925
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 214-739-6644
-----------------------------------------------------
Fax | 214-231-2957
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101Y00000X
-----------------------------------------------------
Taxonomy Name | Counselor
-----------------------------------------------------
License Number | 09655
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 106H00000X
-----------------------------------------------------
Taxonomy Name | Marriage & Family Therapist
-----------------------------------------------------
License Number | 003183-002996
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------