Healthcare Provider Details

I. General information

NPI: 1861353559
Provider Name (Legal Business Name): NICOLE MOY
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/21/2025
Last Update Date: 11/21/2025
Certification Date: 11/20/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

177 W 200 S
VALPARAISO IN
46385-9607
US

IV. Provider business mailing address

177 W 200 S
VALPARAISO IN
46385-9607
US

V. Phone/Fax

Practice location:
  • Phone: 219-973-9584
  • Fax:
Mailing address:
  • Phone: 219-973-9584
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number33012408A
License Number StateIN
# 2
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number33012408A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: