Provider Demographics
NPI:1326866435
Name:MOORE, NICOLE J (CDCA)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:J
Last Name:MOORE
Suffix:
Gender:F
Credentials:CDCA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:29680 PHILLIPS AVE
Mailing Address - Street 2:
Mailing Address - City:WICKLIFFE
Mailing Address - State:OH
Mailing Address - Zip Code:44092-2210
Mailing Address - Country:US
Mailing Address - Phone:216-832-4607
Mailing Address - Fax:
Practice Address - Street 1:134 S SAINT CLAIR ST
Practice Address - Street 2:
Practice Address - City:PAINESVILLE
Practice Address - State:OH
Practice Address - Zip Code:44077-3421
Practice Address - Country:US
Practice Address - Phone:440-255-0678
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-09-27
Last Update Date:2024-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHCDCA.188106101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Single Specialty