Provider Demographics
NPI:1861418956
Name:MOORE, CHARLEEN M (LCSW)
Entity type:Individual
Prefix:
First Name:CHARLEEN
Middle Name:M
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 1:1101 N ROYAL AVE
Mailing Address - Street 2:SUITE B
Mailing Address - City:EVANSVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:47715-7845
Mailing Address - Country:US
Mailing Address - Phone:812-450-6815
Mailing Address - Fax:812-450-6822
Practice Address - Street 1:1101 N ROYAL AVE
Practice Address - Street 2:SUITE B
Practice Address - City:EVANSVILLE
Practice Address - State:IN
Practice Address - Zip Code:47715-7845
Practice Address - Country:US
Practice Address - Phone:812-402-0020
Practice Address - Fax:812-402-0023
Is Sole Proprietor?:No
Enumeration Date:2006-07-14
Last Update Date:2013-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN34002294A1041C0700X
IN35000786A106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000185606OtherANTHEM PIN
IN11495407OtherCAQH
IN11495407OtherCAQH