Provider Demographics
NPI:1942638671
Name:MOORE, VERNON (BGA)
Entity Type:Individual
Prefix:
First Name:VERNON
Middle Name:
Last Name:MOORE
Suffix:
Gender:M
Credentials:BGA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:255 HEMPSTEAD ST
Mailing Address - Street 2:
Mailing Address - City:NEW LONDON
Mailing Address - State:CT
Mailing Address - Zip Code:06320-6204
Mailing Address - Country:US
Mailing Address - Phone:860-443-2896
Mailing Address - Fax:860-442-5909
Practice Address - Street 1:7.5 NORTH THIRD AVE
Practice Address - Street 2:
Practice Address - City:TAFTVILLE
Practice Address - State:CT
Practice Address - Zip Code:06380
Practice Address - Country:US
Practice Address - Phone:404-918-5827
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-10-15
Last Update Date:2013-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical