MEDICARE: CHARLEEN M MOORE LCSW

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker	34002294A	IN
2	106H00000X	Marriage & Family Therapist	35000786A	IN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	000000185606	OTHER	IN	ANTHEM PIN
2	11495407	OTHER	IN	CAQH

General Provider Information

NPI Number	:	1861418956
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CHARLEEN M MOORE LCSW

Provider Business Mailing Address
First Line	:	1101 N ROYAL AVE
Second Line	:	SUITE B
City	:	EVANSVILLE
State	:	IN
Zip	:	47715-7845
Country	:	US
Telephone Number	:	812-450-6815
Fax Number	:	812-450-6822

Provider Business Practice Location Address
First Line	:	1101 N ROYAL AVE
Second Line	:	SUITE B
City	:	EVANSVILLE
State	:	IN
Zip	:	47715-7845
Country	:	US
Telephone Number	:	812-402-0020
Fax Number	:	812-402-0023

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/14/2006
Last Update Date	:	08/20/2013

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Directions to “ CHARLEEN M MOORE LCSW” Practice Location

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