Provider Demographics
NPI:1548356181
Name:MOFFITT, BRYAN CORLEY (LPC)
Entity type:Individual
Prefix:
First Name:BRYAN
Middle Name:CORLEY
Last Name:MOFFITT
Suffix:
Gender:M
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5701 AVENUE P
Mailing Address - Street 2:
Mailing Address - City:LUBBOCK
Mailing Address - State:TX
Mailing Address - Zip Code:79412-3674
Mailing Address - Country:US
Mailing Address - Phone:806-747-3488
Mailing Address - Fax:806-747-3219
Practice Address - Street 1:5701 AVENUE P
Practice Address - Street 2:
Practice Address - City:LUBBOCK
Practice Address - State:TX
Practice Address - Zip Code:79412-3674
Practice Address - Country:US
Practice Address - Phone:806-747-3488
Practice Address - Fax:806-747-3219
Is Sole Proprietor?:No
Enumeration Date:2006-10-04
Last Update Date:2012-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX12735101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX022779OtherVMC EAP
TX152320101Medicaid
TX22100OtherFIRSTCARE COMMERCIAL
TX83479LOtherBCBS TEXAS
TX207800OtherCOMPSYCH EAP