Provider Demographics
NPI:1407883366
Name:MOORE, GEORGE VINCENT JR (LCSW)
Entity Type:Individual
Prefix:MR
First Name:GEORGE
Middle Name:VINCENT
Last Name:MOORE
Suffix:JR
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:890 LONG HILL RD
Mailing Address - Street 2:
Mailing Address - City:MIDDLETOWN
Mailing Address - State:CT
Mailing Address - Zip Code:06457-5063
Mailing Address - Country:US
Mailing Address - Phone:860-347-9911
Mailing Address - Fax:860-347-6413
Practice Address - Street 1:300 PLAZA MIDDLESEX
Practice Address - Street 2:3RD FLOOR
Practice Address - City:MIDDLETOWN
Practice Address - State:CT
Practice Address - Zip Code:06457-3455
Practice Address - Country:US
Practice Address - Phone:860-305-2083
Practice Address - Fax:860-347-8120
Is Sole Proprietor?:No
Enumeration Date:2006-06-27
Last Update Date:2014-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT001602104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
512845OtherVALUE OPTIONS
722242000OtherMAGELLAN
254506OtherMHN
CT4397705OtherAETNA
CT140001602CT02OtherBCBS
061038160OtherCHAMPUS TRICARE
2195892OtherCIGNA
P3192844OtherOXFORD
722242000OtherUBH
2195892OtherCIGNA