Basic Information
| Provider Information | |||||||||
| NPI: | 1972676559 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MOORE | ||||||||
| FirstName: | KATHLEEN | ||||||||
| MiddleName: | ANN | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | LPC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 205 E UNIVERSITY AVE STE 200 | ||||||||
| Address2: | |||||||||
| City: | GEORGETOWN | ||||||||
| State: | TX | ||||||||
| PostalCode: | 786266821 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8778005722 | ||||||||
| FaxNumber: | 5123322180 | ||||||||
| Practice Location | |||||||||
| Address1: | 605 OLD AUSTIN HWY | ||||||||
| Address2: | |||||||||
| City: | BASTROP | ||||||||
| State: | TX | ||||||||
| PostalCode: | 786025034 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8778005722 | ||||||||
| FaxNumber: | 5123322180 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/15/2006 | ||||||||
| LastUpdateDate: | 03/09/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/09/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YP2500X | 13112 | TX | Y | Behavioral Health & Social Service Providers | Counselor | Professional |
ID Information
| ID | Type | State | Issuer | Description | 13112 | 01 | TX | LICENSE | OTHER | 0955437-04 | 05 | TX | MEDICAID |