Provider Demographics
NPI:1386869303
Name:MOORE, CAROLYN R (LCSW)
Entity type:Individual
Prefix:MS
First Name:CAROLYN
Middle Name:R
Last Name:MOORE
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:50 STUTZ BEARCAT DR
Mailing Address - Street 2:SUITE 2
Mailing Address - City:SEDONA
Mailing Address - State:AZ
Mailing Address - Zip Code:86336-5268
Mailing Address - Country:US
Mailing Address - Phone:928-300-4539
Mailing Address - Fax:
Practice Address - Street 1:50 STUTZ BEARCAT DR
Practice Address - Street 2:SUITE 2
Practice Address - City:SEDONA
Practice Address - State:AZ
Practice Address - Zip Code:86336-5268
Practice Address - Country:US
Practice Address - Phone:928-300-4539
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLCSW-100341041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZAZ0913070OtherBCBS OF AZ NON-CONTRACTED