Provider Demographics
NPI:1295248250
Name:MOORER, CHARLENE (NCC, LPC)
Entity type:Individual
Prefix:
First Name:CHARLENE
Middle Name:
Last Name:MOORER
Suffix:
Gender:F
Credentials:NCC, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:246 WOLCOTT RD STE 3
Mailing Address - Street 2:
Mailing Address - City:WOLCOTT
Mailing Address - State:CT
Mailing Address - Zip Code:06716-2641
Mailing Address - Country:US
Mailing Address - Phone:860-329-7672
Mailing Address - Fax:
Practice Address - Street 1:36 N MAIN ST
Practice Address - Street 2:
Practice Address - City:SOUTHINGTON
Practice Address - State:CT
Practice Address - Zip Code:06489-2517
Practice Address - Country:US
Practice Address - Phone:203-919-2229
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-11-13
Last Update Date:2020-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT241420101Y00000X
CT46-002009101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT008076655Medicaid