Active NPI
Stephanie Diane Moore, PSY.D.
- Clinical Psychologist
- Waterford, CT
National Provider Identifier
1396874087
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Clinical Psychologist
- License
- 001668
- Practice address
- 567 Vauxhall Street Extension
#107
Waterford, CT 06385 - Phone
- (860) 439-1980
- Fax
- (860) 388-4460
- NPI assigned
- Mar 5, 2007
- Sex
- Female
- Sole proprietor
- Yes
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Clinical Psychologist | 103TC0700X | 001668 | CT | Primary |
Addresses
Primary practice location
567 Vauxhall Street Extension
#107
Waterford, CT 06385
Mailing address
PO Box 403
Old Saybrook, CT 06475-0403
Phone (860) 536-1536
Other identifiers 1
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 060001668CT02 | Other | CT | ANTHEM BLUE CROSS |
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Enrolled in CT
- Eligible to order & refer
- Part B services: Yes
- Medical equipment: Yes
- Home health: No
- Power mobility devices: No
- Hospice: No
Enrollment records 1
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| I20091109000598 | CT | Practitioner - Clinical Psychologist | 2860530086 | Practice locations: Waterford, CT |
Care Compare profile
Medicare Care Compare- Specialty
- Clinical Psychologist
- Education
- Baylor College of Medicine, 1989
- Medicare assignment
- Accepts the Medicare-approved amount as payment in full
Practice addresses (Care Compare)
567 Vauxhall St Ext
Suite 107
Waterford, CT 06385-4331
Phone (860) 439-1980
567 Vauxhall St Extension
Suite 107
Waterford, CT 06385
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Enrolled
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 001668 | CT | MD | Chiropractor |
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1173052800000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1340150400000",
"number": "1396874087",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "PO BOX 403",
"city": "OLD SAYBROOK",
"state": "CT",
"postal_code": "064750403",
"telephone_number": "860-536-1536"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "567 VAUXHALL STREET EXTENSION",
"address_2": "#107",
"city": "WATERFORD",
"state": "CT",
"postal_code": "06385",
"telephone_number": "860-439-1980",
"fax_number": "860-388-4460"
}
],
"practiceLocations": [],
"basic": {
"last_name": "MOORE",
"first_name": "STEPHANIE",
"middle_name": "DIANE",
"name_prefix": "Dr.",
"credential": "PSY.D.",
"sole_proprietor": "YES",
"sex": "F",
"enumeration_date": "2007-03-05",
"last_updated": "2012-06-20",
"status": "A"
},
"taxonomies": [
{
"code": "103TC0700X",
"taxonomy_group": "",
"desc": "Psychologist, Clinical",
"state": "CT",
"license": "001668",
"primary": true
}
],
"identifiers": [
{
"code": "01",
"desc": "Other (non-Medicare)",
"issuer": "ANTHEM BLUE CROSS",
"identifier": "060001668CT02",
"state": "CT"
}
],
"endpoints": [],
"other_names": []
}Other providers in Waterford, CT
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jun 20, 2012; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; Order and Referring.
- Medicare Care Compare (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.