MEDICARE: LYNN MARIE FAGEN MOORE

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YA0400X	Addiction (Substance Use Disorder) Counselor	302220	MN

General Provider Information

NPI Number	:	1245519388
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LYNN MARIE FAGEN MOORE

Provider Business Mailing Address
First Line	:	11720 256TH ST
Second Line	:
City	:	CHISAGO CITY
State	:	MN
Zip	:	55013-9752
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	11720 256TH ST
Second Line	:
City	:	CHISAGO CITY
State	:	MN
Zip	:	55013-9752
Country	:	US
Telephone Number	:	651-257-4159
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/08/2011
Last Update Date	:	08/08/2011

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