| Doctor Name: | LYNN MARIE FAGEN MOORE |
| NPI Number: | 1245519388 |
| Entity Type Code: | Individual (1) |
| Gender: | F |
| Credentials: | |
| License Number: | 302220 |
| Business Practice Address: | 11720 256th St Chisago City, MN - 550139752 |
| Business Phone Number: | 6512574159 |
| Business Fax Number: | |
| Mailing Address: | 11720 256th St, CHISAGO CITY |
| State: | MN |
| Postal Code: | 550139752 |
| Phone Number: | |
| Fax Number: | |
| NPI Enumeration Date: | 08/08/2011 |
| NPI Last Update Date: | 08/08/2011 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 101YA0400X |
| License Number: | 302220 |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | MN |
| Taxonomy Type: | Behavioral Health & Social Service Providers |
| Taxonomy Classification: | Counselor |
| Taxonomy Specialization: | Addiction (Substance Use Disorder) |
| Taxonomy Definition: | |