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General NPI Number Information
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NPI Number | 1750152203
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Entity Type | Individual
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Provider Name | AMANDA MOORE LPC
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Gender | Female
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Dates
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Enumeration Date | 01/12/2024
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Last Update Date | 01/12/2024
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Provider Practice Location Address
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Address Line | 855 N CAPITAL AVE STE 1
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City | IDAHO FALLS
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State | ID
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Zip | 83402-3405
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Country | US
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Telephone | 208-552-0855
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Fax |
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Provider Business Mailing Address
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Address Line | 2195 LOGAN DR
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City | IDAHO FALLS
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State | ID
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Zip | 83401-4404
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Country | US
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Telephone | 208-357-8909
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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 | 10116
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License Number State | ID
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