Provider Demographics
NPI:1801012422
Name:MOORE, KAREN JO (MS)
Entity Type:Individual
Prefix:MS
First Name:KAREN
Middle Name:JO
Last Name:MOORE
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4243 SUNSHINE AVENUE
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46228-2727
Mailing Address - Country:US
Mailing Address - Phone:317-297-2993
Mailing Address - Fax:317-297-2993
Practice Address - Street 1:4243 SUNSHINE AVE
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46228-2727
Practice Address - Country:US
Practice Address - Phone:317-299-0291
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-18
Last Update Date:2008-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200883840Medicaid