Provider Demographics
NPI:1518907229
Name:MOORE, CARRIE L (MA, LMSW, CAAC)
Entity Type:Individual
Prefix:MS
First Name:CARRIE
Middle Name:L
Last Name:MOORE
Suffix:
Gender:F
Credentials:MA, LMSW, CAAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1110 COBB AVE
Mailing Address - Street 2:
Mailing Address - City:KALAMAZOO
Mailing Address - State:MI
Mailing Address - Zip Code:49007-2450
Mailing Address - Country:US
Mailing Address - Phone:269-349-7148
Mailing Address - Fax:
Practice Address - Street 1:157 S KALAMAZOO MALL
Practice Address - Street 2:250
Practice Address - City:KALAMAZOO
Practice Address - State:MI
Practice Address - Zip Code:49007-4877
Practice Address - Country:US
Practice Address - Phone:269-383-1440
Practice Address - Fax:269-383-9781
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-08
Last Update Date:2010-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6801062534101YM0800X
MIC-02372101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI6801062534OtherLMSW
MIC-02372OtherCAAC
MI1518907229Medicare PIN