Provider Demographics
NPI:1952483661
Name:MOORE, CHRISTINA EYMARD (PSYD)
Entity Type:Individual
Prefix:DR
First Name:CHRISTINA
Middle Name:EYMARD
Last Name:MOORE
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12C LEDGEBROOK DR
Mailing Address - Street 2:
Mailing Address - City:MANSFIELD CENTER
Mailing Address - State:CT
Mailing Address - Zip Code:06250-1664
Mailing Address - Country:US
Mailing Address - Phone:860-208-8944
Mailing Address - Fax:
Practice Address - Street 1:12 C LEDGEBROOK DRIVE
Practice Address - Street 2:
Practice Address - City:MANSFIELD
Practice Address - State:CT
Practice Address - Zip Code:06250-1664
Practice Address - Country:US
Practice Address - Phone:860-208-8944
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT1443103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT060001443CT01OtherANTHEM BLUE CROSS BLUE SH
CT102606OtherVALUEOPTIONS
CT306587OtherMHN