Provider Demographics
NPI:1639809452
Name:MORITZ, NICHOLLE RAE
Entity Type:Individual
Prefix:
First Name:NICHOLLE
Middle Name:RAE
Last Name:MORITZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:617 MORRISON AVE
Mailing Address - Street 2:
Mailing Address - City:PUEBLO
Mailing Address - State:CO
Mailing Address - Zip Code:81005-1719
Mailing Address - Country:US
Mailing Address - Phone:719-553-8350
Mailing Address - Fax:
Practice Address - Street 1:401 BROADWAY AVE
Practice Address - Street 2:
Practice Address - City:PUEBLO
Practice Address - State:CO
Practice Address - Zip Code:81004-2127
Practice Address - Country:US
Practice Address - Phone:719-505-5538
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-14
Last Update Date:2022-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician