Healthcare Provider Details

I. General information

NPI: 1861418956
Provider Name (Legal Business Name): CHARLEEN M MOORE LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/14/2006
Last Update Date: 08/20/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1101 N ROYAL AVE SUITE B
EVANSVILLE IN
47715-7845
US

IV. Provider business mailing address

1101 N ROYAL AVE SUITE B
EVANSVILLE IN
47715-7845
US

V. Phone/Fax

Practice location:
  • Phone: 812-402-0020
  • Fax: 812-402-0023
Mailing address:
  • Phone: 812-450-6815
  • Fax: 812-450-6822

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number34002294A
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number35000786A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: