Healthcare Provider Details

I. General information

NPI: 1487910550
Provider Name (Legal Business Name): NICOLE SULLIVAN MOORE LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/03/2012
Last Update Date: 04/03/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1531 13TH ST SUITE 2540
COLUMBUS IN
47201-1300
US

IV. Provider business mailing address

PO BOX 1002
COLUMBUS IN
47202-1002
US

V. Phone/Fax

Practice location:
  • Phone: 812-372-3745
  • Fax: 812-372-5367
Mailing address:
  • Phone: 812-372-3745
  • Fax: 812-372-5367

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number34003909A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: