Provider Demographics
NPI:1578004867
Name:MOORE, NICOLE (MA)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:MOORE
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:821 DELAWARE AVE SW
Mailing Address - Street 2:UNIT A
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20024-4207
Mailing Address - Country:US
Mailing Address - Phone:703-622-5615
Mailing Address - Fax:
Practice Address - Street 1:821 DELAWARE AVE SW
Practice Address - Street 2:UNIT A
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20024-4207
Practice Address - Country:US
Practice Address - Phone:703-622-5615
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-03-20
Last Update Date:2017-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCLGPC00132101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health