Basic Information
| Provider Information | |||||||||
| NPI: | 1053489666 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MOXLEY | ||||||||
| FirstName: | LISA | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | LPC | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | HANCOCK | ||||||||
| OtherFirstName: | LISA | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | MRS. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | LPE | ||||||||
| OtherLastNameType: | 2 | ||||||||
| Mailing Information | |||||||||
| Address1: | 25 GAP RD | ||||||||
| Address2: | |||||||||
| City: | BATESVILLE | ||||||||
| State: | AR | ||||||||
| PostalCode: | 725018679 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8707938900 | ||||||||
| FaxNumber: | 8707938959 | ||||||||
| Practice Location | |||||||||
| Address1: | 1109 E MAIN ST | ||||||||
| Address2: | |||||||||
| City: | MELBOURNE | ||||||||
| State: | AR | ||||||||
| PostalCode: | 72556 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8703684397 | ||||||||
| FaxNumber: | 8703687828 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/01/2006 | ||||||||
| LastUpdateDate: | 04/08/2009 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101Y00000X | P0107030 | AR | N | Behavioral Health & Social Service Providers | Counselor | 101YA0400X | P0107030 | AR | N | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 101YM0800X | P0107030 | AR | N | Behavioral Health & Social Service Providers | Counselor | Mental Health | 101YP2500X | P0107030 | AR | Y | Behavioral Health & Social Service Providers | Counselor | Professional |
No ID Information.