Provider Demographics
NPI:1316193261
Name:MOORE, CAROLYN (MA)
Entity Type:Individual
Prefix:
First Name:CAROLYN
Middle Name:
Last Name:MOORE
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:CAROLYN
Other - Middle Name:
Other - Last Name:BEACH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:105 WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:VALPARAISO
Mailing Address - State:IN
Mailing Address - Zip Code:46383-4729
Mailing Address - Country:US
Mailing Address - Phone:219-968-8827
Mailing Address - Fax:219-321-1211
Practice Address - Street 1:105 WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:VALPARAISO
Practice Address - State:IN
Practice Address - Zip Code:46383-4729
Practice Address - Country:US
Practice Address - Phone:219-968-8827
Practice Address - Fax:219-321-1211
Is Sole Proprietor?:Yes
Enumeration Date:2008-08-12
Last Update Date:2019-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health