Basic Information
| Provider Information | |||||||||
| NPI: | 1669656484 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MOORE | ||||||||
| FirstName: | QUEENIE | ||||||||
| MiddleName: | MAE | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | MOORE | ||||||||
| OtherFirstName: | QUEENIE | ||||||||
| OtherMiddleName: | CONNER | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | MS, LADC | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 221 HOWARD AVE | ||||||||
| Address2: | NONE | ||||||||
| City: | NEW HAVEN | ||||||||
| State: | CT | ||||||||
| PostalCode: | 065192727 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2037814646 | ||||||||
| FaxNumber: | 2037814705 | ||||||||
| Practice Location | |||||||||
| Address1: | 1415 STATE ST | ||||||||
| Address2: | |||||||||
| City: | NEW HAVEN | ||||||||
| State: | CT | ||||||||
| PostalCode: | 065112702 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2036911038 | ||||||||
| FaxNumber: | 2036911038 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/28/2007 | ||||||||
| LastUpdateDate: | 12/28/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101Y00000X | 000755 | CT | Y | Behavioral Health & Social Service Providers | Counselor |
No ID Information.