Provider Demographics
NPI:1114254380
Name:MOORE, CAROL E (LADC)
Entity type:Individual
Prefix:
First Name:CAROL
Middle Name:E
Last Name:MOORE
Suffix:
Gender:F
Credentials:LADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:914 S 8TH ST # S131
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55404-1210
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:914 S 8TH ST # S131
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55404-1210
Practice Address - Country:US
Practice Address - Phone:612-347-7600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-11-10
Last Update Date:2009-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN302205101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)