Individual
IVONNE MOORE III
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
BA
Contact information
Practice address
484 MAIN ST, SUITE 450, WORCESTER, MA 01608-1893
(508) 752-2590
(508) 753-5051
Mailing address
105 MERRICK ST, WORCESTER, MA 01609-1937
(508) 797-6100
(508) 797-0693
Taxonomy
Speciality
Code
Description
License number
State
101YA0400X
Addiction (Substance Use Disorder) Counselor
Primary
—
—
101YM0800X
Mental Health Counselor
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
1306461
—
MA
05
—
1308785
—
MA
01
—
22220002001
BLUE CROSS
MA
01
—
M18684
BLUE CROSS
MA
Enumeration date
07/21/2011
Last updated
07/21/2011
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