Healthcare Provider Details

I. General information

NPI: 1609551787
Provider Name (Legal Business Name): MOXIE NOVA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/16/2023
Last Update Date: 02/20/2024
Certification Date: 02/20/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1820 CENTRAL AVE
ESTHERVILLE IA
51334-2409
US

IV. Provider business mailing address

PO BOX 308
ESTHERVILLE IA
51334-0308
US

V. Phone/Fax

Practice location:
  • Phone: 712-340-7323
  • Fax: 712-560-9088
Mailing address:
  • Phone: 712-340-7323
  • Fax: 712-560-9088

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name: AMANDA JADE OLSON
Title or Position: OWNER & CEO
Credential:
Phone: 712-340-7323