Basic Information
| Provider Information | |||||||||
| NPI: | 1285044958 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MOORE | ||||||||
| FirstName: | REGINA | ||||||||
| MiddleName: | J. | ||||||||
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| Credential: | M.ED., LPC, NCC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3584 COURTLAND DR | ||||||||
| Address2: | |||||||||
| City: | BATON ROUGE | ||||||||
| State: | LA | ||||||||
| PostalCode: | 708142810 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2253022123 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 12097 OLD HAMMOND HWY STE I4 | ||||||||
| Address2: | |||||||||
| City: | BATON ROUGE | ||||||||
| State: | LA | ||||||||
| PostalCode: | 70816 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2252468816 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/05/2014 | ||||||||
| LastUpdateDate: | 06/26/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YP2500X | 4401 | LA | Y | Behavioral Health & Social Service Providers | Counselor | Professional |
ID Information
| ID | Type | State | Issuer | Description | 101YP2500X | 05 | LA | MEDICAID |