MEDICARE: MRS. HENRIETTA LOUISE MOORE M.ED,LMFT

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	106H00000X	Marriage & Family Therapist	LF00001032	WA

General Provider Information

NPI Number	:	1508923152
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. HENRIETTA LOUISE MOORE M.ED,LMFT

Provider Business Mailing Address
First Line	:	5244 DEERFIELD PARK CT NE
Second Line	:
City	:	OLYMPIA
State	:	WA
Zip	:	98516-2131
Country	:	US
Telephone Number	:	360-491-7212
Fax Number	:

Provider Business Practice Location Address
First Line	:	612 CARPENTER RD SE
Second Line	:
City	:	OLYMPIA
State	:	WA
Zip	:	98503-1383
Country	:	US
Telephone Number	:	360-951-7540
Fax Number	:

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

Provider Enumeration Date	:	01/02/2007
Last Update Date	:	07/08/2007

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