Healthcare Provider Details

I. General information

NPI: 1881763779
Provider Name (Legal Business Name): ELLEN CF MOORE LCMHC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/07/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18 TULIP STREET
LYNDONVILLE VT
05851
US

IV. Provider business mailing address

PO BOX 1161
LYNDONVILLE VT
05851-1161
US

V. Phone/Fax

Practice location:
  • Phone: 802-626-8189
  • Fax: 704-987-8746
Mailing address:
  • Phone: 802-626-8189
  • Fax: 704-987-8746

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number0680000355
License Number StateVT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: