Provider Demographics
NPI:1720068182
Name:MOORE, CAROLYN MAE (LCSW)
Entity Type:Individual
Prefix:MRS
First Name:CAROLYN
Middle Name:MAE
Last Name:MOORE
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 100
Mailing Address - Street 2:
Mailing Address - City:ALBANY
Mailing Address - State:OR
Mailing Address - Zip Code:97321-0031
Mailing Address - Country:US
Mailing Address - Phone:541-451-5932
Mailing Address - Fax:
Practice Address - Street 1:1600 S MAIN ST
Practice Address - Street 2:
Practice Address - City:LEBANON
Practice Address - State:OR
Practice Address - Zip Code:97355-3109
Practice Address - Country:US
Practice Address - Phone:541-451-5932
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-20
Last Update Date:2018-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORL42041041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500612327Medicaid
UT107029555101OtherINTRMTN. HEALTH CARE
UT942938348015OtherCHAMPUS
UT942938348CMMOtherEDUCATORS MUTUAL
UT003104017Medicare ID - Type UnspecifiedRAILROAD MEDICARE
UT003104017Medicare ID - Type UnspecifiedMEDICARE
UT832613OtherDESERET MUTUAL