Provider Demographics
NPI:1437251212
Name:MOFFAT MCGARRY, NACOLE A (LCSW)
Entity Type:Individual
Prefix:
First Name:NACOLE
Middle Name:A
Last Name:MOFFAT MCGARRY
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:NACOLE
Other - Middle Name:A
Other - Last Name:MOFFAT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:9461 BRANDYWINE LN
Mailing Address - Street 2:
Mailing Address - City:PORT ST LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34986-3307
Mailing Address - Country:US
Mailing Address - Phone:772-429-3600
Mailing Address - Fax:772-429-4589
Practice Address - Street 1:9461 BRANDYWINE LN
Practice Address - Street 2:
Practice Address - City:PORT ST LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34986-3307
Practice Address - Country:US
Practice Address - Phone:772-429-3600
Practice Address - Fax:772-429-4589
Is Sole Proprietor?:No
Enumeration Date:2006-09-02
Last Update Date:2021-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSW72121041C0700X
FLSW 7212101YM0800X
NCC007003101YP2500X, 1041C0700X, 106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL766498200Medicaid
FL766498200Medicaid