1417971656 NPI number — NANCY MOORE L I C S W

Table of content: NANCY MOORE L I C S W (NPI 1417971656)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1417971656 NPI number — NANCY MOORE L I C S W

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MOORE
Provider First Name:
NANCY
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
L I C S W
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1417971656
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/16/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
34 BULLIVANT FARM RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MARION
Provider Business Mailing Address State Name:
MA
Provider Business Mailing Address Postal Code:
02738-1150
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
508-748-2331
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
63 MAIN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BRIDGEWATER
Provider Business Practice Location Address State Name:
MA
Provider Business Practice Location Address Postal Code:
02324-1455
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
508-697-9722
Provider Business Practice Location Address Fax Number:
508-279-0094
Provider Enumeration Date:
07/27/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 1041C0700X , with the licence number:  1021424 , registered in the state of MA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 2143391 . This is a "CIGNA BEH. HEALTH" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 231145 . This is a "COM PSYCH" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: PO6437 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 334612 . This is a "MHN/TRICARE CHAMPUS" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 424872 . This is a "HARVARD/PILGRIM" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 1854780 , issued by the state of ( MA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 62-92900 . This is a "UNITED HEALTH CARE OF N.E" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 642208 . This is a "TUFTS" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".




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