Provider Demographics
NPI:1669986873
Name:MOORE, NICO (LPC,)
Entity type:Individual
Prefix:
First Name:NICO
Middle Name:
Last Name:MOORE
Suffix:
Gender:F
Credentials:LPC,
Other - Prefix:
Other - First Name:NICO
Other - Middle Name:GILSON
Other - Last Name:MOORE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3715 BAINBRIDGE RD
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND HEIGHTS
Mailing Address - State:OH
Mailing Address - Zip Code:44118-2243
Mailing Address - Country:US
Mailing Address - Phone:216-262-5413
Mailing Address - Fax:
Practice Address - Street 1:3100 E 45TH ST STE 212
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44127-1093
Practice Address - Country:US
Practice Address - Phone:216-341-5510
Practice Address - Fax:216-341-5530
Is Sole Proprietor?:No
Enumeration Date:2017-11-27
Last Update Date:2017-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHC.1700796101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional