Provider Demographics
NPI:1417971656
Name:MOORE, NANCY (L I C S W)
Entity Type:Individual
Prefix:
First Name:NANCY
Middle Name:
Last Name:MOORE
Suffix:
Gender:F
Credentials:L I C S W
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:34 BULLIVANT FARM RD
Mailing Address - Street 2:
Mailing Address - City:MARION
Mailing Address - State:MA
Mailing Address - Zip Code:02738-1150
Mailing Address - Country:US
Mailing Address - Phone:508-748-2331
Mailing Address - Fax:
Practice Address - Street 1:63 MAIN ST
Practice Address - Street 2:
Practice Address - City:BRIDGEWATER
Practice Address - State:MA
Practice Address - Zip Code:02324-1455
Practice Address - Country:US
Practice Address - Phone:508-697-9722
Practice Address - Fax:508-279-0094
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-27
Last Update Date:2008-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA10214241041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA2143391OtherCIGNA BEH. HEALTH
MA231145OtherCOM PSYCH
MAPO6437OtherBLUE CROSS BLUE SHIELD
MA334612OtherMHN/TRICARE CHAMPUS
MA424872OtherHARVARD/PILGRIM
MA1854780Medicaid
MA62-92900OtherUNITED HEALTH CARE OF N.E
MA642208OtherTUFTS
MAPO6437OtherBLUE CROSS BLUE SHIELD
MAP00113155Medicare PIN