Provider Demographics
NPI:1457831901
Name:MOODY, NICOLE (LMFT)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:MOODY
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:620 ERIE BLVD W STE 208
Mailing Address - Street 2:
Mailing Address - City:SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13204-2457
Mailing Address - Country:US
Mailing Address - Phone:315-472-7363
Mailing Address - Fax:315-701-2368
Practice Address - Street 1:620 ERIE BLVD W STE 208
Practice Address - Street 2:
Practice Address - City:SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13204-2457
Practice Address - Country:US
Practice Address - Phone:315-472-7363
Practice Address - Fax:315-701-2368
Is Sole Proprietor?:No
Enumeration Date:2018-08-15
Last Update Date:2020-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYP12131101Y00000X
NY001645106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY1336163963Medicaid