Provider Demographics
NPI:1851082333
Name:MOORE, ANDREA JANICE
Entity Type:Individual
Prefix:
First Name:ANDREA
Middle Name:JANICE
Last Name:MOORE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11 GEORGE ST
Mailing Address - Street 2:
Mailing Address - City:MORRISVILLE
Mailing Address - State:VT
Mailing Address - Zip Code:05661-6046
Mailing Address - Country:US
Mailing Address - Phone:315-560-2406
Mailing Address - Fax:
Practice Address - Street 1:28 ELM ST UNIT 3
Practice Address - Street 2:
Practice Address - City:MONTPELIER
Practice Address - State:VT
Practice Address - Zip Code:05602-2814
Practice Address - Country:US
Practice Address - Phone:315-560-2406
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-05-16
Last Update Date:2023-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT097.0135538101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health