1396874087 NPI number — DR. STEPHANIE DIANE MOORE PSY.D.

Table of content: DR. STEPHANIE DIANE MOORE PSY.D. (NPI 1396874087)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1396874087 NPI number — DR. STEPHANIE DIANE MOORE PSY.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MOORE
Provider First Name:
STEPHANIE
Provider Middle Name:
DIANE
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
PSY.D.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1396874087
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/20/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 403
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
OLD SAYBROOK
Provider Business Mailing Address State Name:
CT
Provider Business Mailing Address Postal Code:
06475-0403
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
860-536-1536
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
567 VAUXHALL STREET EXTENSION
Provider Second Line Business Practice Location Address:
#107
Provider Business Practice Location Address City Name:
WATERFORD
Provider Business Practice Location Address State Name:
CT
Provider Business Practice Location Address Postal Code:
06385
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
860-439-1980
Provider Business Practice Location Address Fax Number:
860-388-4460
Provider Enumeration Date:
03/05/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 103TC0700X , with the licence number:  001668 , registered in the state of CT ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 060001668CT02 . This is a "ANTHEM BLUE CROSS" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".




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