Provider Demographics
NPI:1952175853
Name:MOORE, KATHLEEN (MS)
Entity Type:Individual
Prefix:PROF
First Name:KATHLEEN
Middle Name:
Last Name:MOORE
Suffix:
Gender:F
Credentials:MS
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 39
Mailing Address - Street 2:
Mailing Address - City:MARSHFIELD
Mailing Address - State:VT
Mailing Address - Zip Code:05658-0039
Mailing Address - Country:US
Mailing Address - Phone:802-793-4650
Mailing Address - Fax:
Practice Address - Street 1:782 ENNIS HILL ROAD - CABIN
Practice Address - Street 2:
Practice Address - City:MARSHFIELD
Practice Address - State:VT
Practice Address - Zip Code:05658
Practice Address - Country:US
Practice Address - Phone:802-793-4650
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-11-10
Last Update Date:2023-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT097.0115070101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor