Provider Demographics
NPI:1508684804
Name:MOORE, CARRIE RENAE (SAC-IT)
Entity type:Individual
Prefix:
First Name:CARRIE
Middle Name:RENAE
Last Name:MOORE
Suffix:
Gender:F
Credentials:SAC-IT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1826 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:RACINE
Mailing Address - State:WI
Mailing Address - Zip Code:53402-4711
Mailing Address - Country:US
Mailing Address - Phone:262-752-8659
Mailing Address - Fax:
Practice Address - Street 1:6321 23RD AVE
Practice Address - Street 2:
Practice Address - City:KENOSHA
Practice Address - State:WI
Practice Address - Zip Code:53143-4805
Practice Address - Country:US
Practice Address - Phone:262-671-1625
Practice Address - Fax:866-719-3024
Is Sole Proprietor?:Yes
Enumeration Date:2024-09-26
Last Update Date:2024-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI20205-130101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)