Provider Demographics
NPI:1619265832
Name:MOORE, IVONNE III (BA)
Entity Type:Individual
Prefix:
First Name:IVONNE
Middle Name:
Last Name:MOORE
Suffix:III
Gender:F
Credentials:BA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:105 MERRICK ST
Mailing Address - Street 2:
Mailing Address - City:WORCESTER
Mailing Address - State:MA
Mailing Address - Zip Code:01609-1937
Mailing Address - Country:US
Mailing Address - Phone:508-797-6100
Mailing Address - Fax:508-797-0693
Practice Address - Street 1:484 MAIN ST
Practice Address - Street 2:SUITE 450
Practice Address - City:WORCESTER
Practice Address - State:MA
Practice Address - Zip Code:01608-1893
Practice Address - Country:US
Practice Address - Phone:508-752-2590
Practice Address - Fax:508-753-5051
Is Sole Proprietor?:No
Enumeration Date:2011-07-21
Last Update Date:2011-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA1308785Medicaid
MA22220002001OtherBLUE CROSS
MA1306461Medicaid
MAM18684OtherBLUE CROSS
MA1306461Medicaid