Healthcare Provider Details

I. General information

NPI: 1457428484
Provider Name (Legal Business Name): CARLY LYNN MOE LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/28/2006
Last Update Date: 07/02/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1200 HILYARD ST SUITE 540
EUGENE OR
97401-8122
US

IV. Provider business mailing address

1200 HILYARD ST SUITE 540
EUGENE OR
97401-8122
US

V. Phone/Fax

Practice location:
  • Phone: 458-205-7101
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberL5867
License Number StateOR

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: