Provider Demographics
NPI:1346384658
Name:MOON, NICOLETTE STATON (LCSW)
Entity Type:Individual
Prefix:
First Name:NICOLETTE
Middle Name:STATON
Last Name:MOON
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 1:10299 WOODMAN RD
Mailing Address - Street 2:
Mailing Address - City:GLEN ALLEN
Mailing Address - State:VA
Mailing Address - Zip Code:23060-4419
Mailing Address - Country:US
Mailing Address - Phone:804-727-8500
Mailing Address - Fax:804-727-8580
Practice Address - Street 1:10299 WOODMAN RD
Practice Address - Street 2:
Practice Address - City:GLEN ALLEN
Practice Address - State:VA
Practice Address - Zip Code:23060-4419
Practice Address - Country:US
Practice Address - Phone:804-727-8500
Practice Address - Fax:804-727-8580
Is Sole Proprietor?:No
Enumeration Date:2007-02-19
Last Update Date:2008-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA09040033081041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAO89418OtherOPTIMA
VA4945131OtherVIRGINIA PREMIER
VA205825OtherANTHEM
VA263166-000OtherMAGELLAN
VA2169372OtherMAMSI
VA263166-000OtherMAGELLAN