MEDICARE: BONNIE MADELINE MOORE MA, LPC

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	103TC1900X	Counseling Psychologist	19539 233304	TX
2	103TF0200X	Forensic Psychologist	19539 233304	TX
3	103K00000X	Behavior Analyst	19539 233304	TX
4	101YP2500X	Professional Counselor	19539 233304	TX
5	101YP2500X	Professional Counselor	19539	TX
6	102L00000X	Psychoanalyst	19539	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	760323389	OTHER	TX	CIGNA HEALTHCARE
2	256874	OTHER	TX	OLD COMPSYCH
3	570718	OTHER	TX	VALUEOPTIONS MHS#
4	11664355	OTHER	TX	OLD AETNA BEHAVIORAL HEALTH
5	1477756278	OTHER	TX	PURPOSE PSYCHOLOGY NPI
6	403328	OTHER	TX	PURPOSE PSYCHOLOGY'S MHN #
7	85495L	OTHER	TX	BCBS
8	H07190LC01	OTHER	TX	OLD BCBS
9	2554015	OTHER	TX	CIGNA BEHAVIORAL HEALTH
10	365283	OTHER	TX	MHN PROVIDER ID
11	H00028QK01	OTHER	TX	PURPOSE PSYCHOLOGY BCBS
12	H07280LC01	OTHER	TX	OLD BCBS NUMBER
13	H085495L	OTHER	TX	BCBS FULL NUMBER
14	21299221648	OTHER	TX	BEECHSTREET
15	9443845	OTHER	TX	OLD PHCS MULTI-PLAN

General Provider Information

NPI Number	:	1376633214
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BONNIE MADELINE MOORE MA, LPC

Provider Business Mailing Address
First Line	:	1922 WAGON GAP TRL
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77090-1026
Country	:	US
Telephone Number	:	281-444-9553
Fax Number	:	281-444-9553

Provider Business Practice Location Address
First Line	:	1922 WAGON GAP TRL
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77090-1026
Country	:	US
Telephone Number	:	281-444-9553
Fax Number	:	281-444-9553

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

Provider Enumeration Date	:	10/13/2006
Last Update Date	:	01/30/2011

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