Provider Demographics
NPI:1104988500
Name:MOORE, CHARLES N JR (DMIN)
Entity type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:N
Last Name:MOORE
Suffix:JR
Gender:M
Credentials:DMIN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:23 SPRING ST
Mailing Address - Street 2:
Mailing Address - City:ESSEX
Mailing Address - State:MA
Mailing Address - Zip Code:01929-1311
Mailing Address - Country:US
Mailing Address - Phone:978-884-8641
Mailing Address - Fax:
Practice Address - Street 1:23 SPRING ST
Practice Address - Street 2:
Practice Address - City:ESSEX
Practice Address - State:MA
Practice Address - Zip Code:01929-1311
Practice Address - Country:US
Practice Address - Phone:978-884-8641
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA2097103TC0700X, 103TF0000X, 103TF0200X, 103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Not Answered103TF0000XBehavioral Health & Social Service ProvidersPsychologistFamily
Not Answered103TF0200XBehavioral Health & Social Service ProvidersPsychologistForensic
Not Answered103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAWO2327Medicare ID - Type UnspecifiedCLINICAL PSYCHOLOGIST