Basic Information
Provider Information | |||||||||
NPI: | 1629373584 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | BUTLER-MOORE | ||||||||
FirstName: | LINDA | ||||||||
MiddleName: | ANN | ||||||||
NamePrefix: | MRS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | LPC | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | MOORE | ||||||||
OtherFirstName: | LINDA | ||||||||
OtherMiddleName: | ANN | ||||||||
OtherNamePrefix: | MRS. | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | LMFT | ||||||||
OtherLastNameType: | 5 | ||||||||
Mailing Information | |||||||||
Address1: | 1000 CHINABERRY DR STE 900 | ||||||||
Address2: |   | ||||||||
City: | BOSSIER CITY | ||||||||
State: | LA | ||||||||
PostalCode: | 711112455 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3187423408 | ||||||||
FaxNumber: | 3188411210 | ||||||||
Practice Location | |||||||||
Address1: | 1301 YOUREE DR | ||||||||
Address2: |   | ||||||||
City: | SHREVEPORT | ||||||||
State: | LA | ||||||||
PostalCode: | 711015117 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3186750804 | ||||||||
FaxNumber: | 3184259030 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 01/24/2011 | ||||||||
LastUpdateDate: | 09/30/2019 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YP2500X | 2275 | LA | Y |   | Behavioral Health & Social Service Providers | Counselor | Professional |
No ID Information.