Provider Demographics
NPI:1710358445
Name:MOORE, KENNETH STEVEN (MHP)
Entity Type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:STEVEN
Last Name:MOORE
Suffix:
Gender:M
Credentials:MHP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 LEDGEHILL RD
Mailing Address - Street 2:
Mailing Address - City:BENNINGTON
Mailing Address - State:VT
Mailing Address - Zip Code:05201-2273
Mailing Address - Country:US
Mailing Address - Phone:802-442-5491
Mailing Address - Fax:
Practice Address - Street 1:100 LEDGEHILL RD
Practice Address - Street 2:
Practice Address - City:BENNINGTON
Practice Address - State:VT
Practice Address - Zip Code:05201-2273
Practice Address - Country:US
Practice Address - Phone:802-442-5491
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-10-07
Last Update Date:2015-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT0970113490103TF0000X
103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TF0000XBehavioral Health & Social Service ProvidersPsychologistFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT0970113490OtherBCBS