Provider Demographics
NPI:1346507480
Name:MOORE, CAROLE WHITAKER (LCSW, BCD)
Entity Type:Individual
Prefix:
First Name:CAROLE
Middle Name:WHITAKER
Last Name:MOORE
Suffix:
Gender:F
Credentials:LCSW, BCD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:110 UNION BELLE BLVD
Mailing Address - Street 2:
Mailing Address - City:SALTILLO
Mailing Address - State:MS
Mailing Address - Zip Code:38866-0000
Mailing Address - Country:US
Mailing Address - Phone:662-869-3042
Mailing Address - Fax:662-869-3405
Practice Address - Street 1:110 UNION BELLE BLVD
Practice Address - Street 2:
Practice Address - City:SALTILLO
Practice Address - State:MS
Practice Address - Zip Code:38866-0000
Practice Address - Country:US
Practice Address - Phone:662-869-3042
Practice Address - Fax:662-869-3405
Is Sole Proprietor?:Yes
Enumeration Date:2012-04-13
Last Update Date:2012-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSC0206104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker