Provider Demographics
NPI:1649604885
Name:MOORE, HEATHER RENEE (MA, LPC)
Entity type:Individual
Prefix:
First Name:HEATHER
Middle Name:RENEE
Last Name:MOORE
Suffix:
Gender:F
Credentials:MA, LPC
Other - Prefix:
Other - First Name:HEATHER
Other - Middle Name:RENEE
Other - Last Name:JONES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:550 S PEORIA AVE
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74120-3820
Mailing Address - Country:US
Mailing Address - Phone:918-588-1900
Mailing Address - Fax:918-382-1285
Practice Address - Street 1:550 S PEORIA AVE
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74120-3820
Practice Address - Country:US
Practice Address - Phone:918-588-1900
Practice Address - Fax:918-382-1285
Is Sole Proprietor?:No
Enumeration Date:2013-08-23
Last Update Date:2020-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK5751101YM0800X, 101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK13618765OtherCAQH
OK200506310-AMedicaid