Healthcare Provider Details

I. General information

NPI: 1528311404
Provider Name (Legal Business Name): CAROLINE MOORE PH.D., LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/17/2012
Last Update Date: 06/06/2022
Certification Date: 06/05/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1718 LE ROY AVE
BERKELEY CA
94709-1116
US

IV. Provider business mailing address

1718 LE ROY AVE
BERKELEY CA
94709-1116
US

V. Phone/Fax

Practice location:
  • Phone: 602-430-8306
  • Fax: 917-591-7417
Mailing address:
  • Phone: 602-430-8306
  • Fax: 917-591-7417

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number075903-1
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number87033
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: