Basic Information
| Provider Information | |||||||||
| NPI: | 1851798698 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MOORE | ||||||||
| FirstName: | DANA | ||||||||
| MiddleName: | W | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PH.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | WIEBE | ||||||||
| OtherFirstName: | DANA | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | DR. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | PH.D. | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 69 SAND PIT RD | ||||||||
| Address2: | SUITE 300 | ||||||||
| City: | DANBURY | ||||||||
| State: | CT | ||||||||
| PostalCode: | 068104004 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2037482551 | ||||||||
| FaxNumber: | 2037906375 | ||||||||
| Practice Location | |||||||||
| Address1: | 69 SAND PIT RD | ||||||||
| Address2: | SUITE 300 | ||||||||
| City: | DANBURY | ||||||||
| State: | CT | ||||||||
| PostalCode: | 068104004 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2037482551 | ||||||||
| FaxNumber: | 2037906375 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/21/2014 | ||||||||
| LastUpdateDate: | 01/20/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103G00000X | 3392 | CT | Y | Behavioral Health & Social Service Providers | Clinical Neuropsychologist |
No ID Information.