Provider Demographics
NPI:1881763779
Name:MOORE, ELLEN CF (LCMHC)
Entity type:Individual
Prefix:
First Name:ELLEN
Middle Name:CF
Last Name:MOORE
Suffix:
Gender:F
Credentials:LCMHC
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 1161
Mailing Address - Street 2:
Mailing Address - City:LYNDONVILLE
Mailing Address - State:VT
Mailing Address - Zip Code:05851-1161
Mailing Address - Country:US
Mailing Address - Phone:802-626-8189
Mailing Address - Fax:704-987-8746
Practice Address - Street 1:18 TULIP STREET
Practice Address - Street 2:
Practice Address - City:LYNDONVILLE
Practice Address - State:VT
Practice Address - Zip Code:05851
Practice Address - Country:US
Practice Address - Phone:802-626-8189
Practice Address - Fax:704-987-8746
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT0680000355101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT1049971OtherCIGNA
VT711988OtherMOHAWK VALLEY PLAN
VT00029643OtherBCBS
VT1007327Medicaid