Healthcare Provider Details

I. General information

NPI: 1588729867
Provider Name (Legal Business Name): CAROL ANNE MOORE M.A.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/27/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

160 BENMONT AVE
BENNINGTON VT
05201-1873
US

IV. Provider business mailing address

160 BENMONT AVE
BENNINGTON VT
05201-1873
US

V. Phone/Fax

Practice location:
  • Phone: 802-442-3520
  • Fax: 802-447-3392
Mailing address:
  • Phone: 802-442-3520
  • Fax: 802-447-3392

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License Number047-0000524
License Number StateVT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: