Provider Demographics
NPI:1316142458
Name:MOORE, DENISE (MSW, LCSW, LCAC)
Entity type:Individual
Prefix:
First Name:DENISE
Middle Name:
Last Name:MOORE
Suffix:
Gender:F
Credentials:MSW, LCSW, LCAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11604 WHIDBEY DR
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46229-2864
Mailing Address - Country:US
Mailing Address - Phone:317-413-8000
Mailing Address - Fax:317-894-4777
Practice Address - Street 1:5502 E 16TH ST
Practice Address - Street 2:SUITE C-16
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46218-4937
Practice Address - Country:US
Practice Address - Phone:317-466-1000
Practice Address - Fax:317-894-4777
Is Sole Proprietor?:No
Enumeration Date:2007-06-19
Last Update Date:2013-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN3305215A104100000X
IN34006718A1041C0700X
IN87000624A101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100462120Medicaid
IN100462120Medicaid