Provider Demographics
NPI:1689799231
Name:MOORE, ELIZABETH L (PHD)
Entity Type:Individual
Prefix:DR
First Name:ELIZABETH
Middle Name:L
Last Name:MOORE
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 W CENTER ST STE C3
Mailing Address - Street 2:
Mailing Address - City:MANCHESTER
Mailing Address - State:CT
Mailing Address - Zip Code:06040-4870
Mailing Address - Country:US
Mailing Address - Phone:860-880-1334
Mailing Address - Fax:
Practice Address - Street 1:200 W CENTER ST STE C3
Practice Address - Street 2:
Practice Address - City:MANCHESTER
Practice Address - State:CT
Practice Address - Zip Code:06040-4870
Practice Address - Country:US
Practice Address - Phone:860-880-1334
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-20
Last Update Date:2020-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT002838103T00000X, 103TC0700X, 103TC1900X
WI2668103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling
No103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT008028383Medicaid
CT680001925 (C00814)Medicare PIN