Provider Demographics
NPI:1760224570
Name:MOORE, CHARLOTTE (LAC)
Entity type:Individual
Prefix:
First Name:CHARLOTTE
Middle Name:
Last Name:MOORE
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:38 NOEL DR
Mailing Address - Street 2:
Mailing Address - City:NORTH ARLINGTON
Mailing Address - State:NJ
Mailing Address - Zip Code:07031-5310
Mailing Address - Country:US
Mailing Address - Phone:201-708-3360
Mailing Address - Fax:
Practice Address - Street 1:169 CHESTNUT ST
Practice Address - Street 2:
Practice Address - City:NUTLEY
Practice Address - State:NJ
Practice Address - Zip Code:07110-2311
Practice Address - Country:US
Practice Address - Phone:973-667-1884
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-06-11
Last Update Date:2024-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ37AC00611900101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health