Provider Demographics
NPI:1669656484
Name:MOORE, QUEENIE MAE
Entity Type:Individual
Prefix:MS
First Name:QUEENIE
Middle Name:MAE
Last Name:MOORE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:QUEENIE
Other - Middle Name:CONNER
Other - Last Name:MOORE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MS, LADC
Mailing Address - Street 1:221 HOWARD AVE
Mailing Address - Street 2:NONE
Mailing Address - City:NEW HAVEN
Mailing Address - State:CT
Mailing Address - Zip Code:06519-2727
Mailing Address - Country:US
Mailing Address - Phone:203-781-4646
Mailing Address - Fax:203-781-4705
Practice Address - Street 1:1415 STATE ST
Practice Address - Street 2:
Practice Address - City:NEW HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06511-2702
Practice Address - Country:US
Practice Address - Phone:203-691-1038
Practice Address - Fax:203-691-1038
Is Sole Proprietor?:Yes
Enumeration Date:2007-12-28
Last Update Date:2007-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT000755101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor