Healthcare Provider Details

I. General information

NPI: 1922699602
Provider Name (Legal Business Name): CAROLYN MERCEDES MOORE MSW, LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/27/2021
Last Update Date: 09/22/2026
Certification Date: 09/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4700 N HABANA AVE STE 703
TAMPA FL
33614-7122
US

IV. Provider business mailing address

9481 DOWDEN RD APT 5102
ORLANDO FL
32832
US

V. Phone/Fax

Practice location:
  • Phone: 941-499-0463
  • Fax:
Mailing address:
  • Phone: 850-450-3146
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number16965
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberSW16965
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: