Provider Demographics
NPI:1487910550
Name:MOORE, NICOLE SULLIVAN (LCSW)
Entity type:Individual
Prefix:MS
First Name:NICOLE
Middle Name:SULLIVAN
Last Name:MOORE
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1002
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:IN
Mailing Address - Zip Code:47202-1002
Mailing Address - Country:US
Mailing Address - Phone:812-372-3745
Mailing Address - Fax:812-372-5367
Practice Address - Street 1:1531 13TH ST
Practice Address - Street 2:SUITE 2540
Practice Address - City:COLUMBUS
Practice Address - State:IN
Practice Address - Zip Code:47201-1300
Practice Address - Country:US
Practice Address - Phone:812-372-3745
Practice Address - Fax:812-372-5367
Is Sole Proprietor?:No
Enumeration Date:2012-04-03
Last Update Date:2012-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN34003909A1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical