Basic Information
| Provider Information | |||||||||
| NPI: | 1316142458 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MOORE | ||||||||
| FirstName: | DENISE | ||||||||
| MiddleName: | |||||||||
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| Credential: | MSW, LCSW, LCAC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 11604 WHIDBEY DR | ||||||||
| Address2: | |||||||||
| City: | INDIANAPOLIS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 462292864 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3174138000 | ||||||||
| FaxNumber: | 3178944777 | ||||||||
| Practice Location | |||||||||
| Address1: | 5502 E 16TH ST | ||||||||
| Address2: | SUITE C-16 | ||||||||
| City: | INDIANAPOLIS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 462184937 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3174661000 | ||||||||
| FaxNumber: | 3178944777 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/19/2007 | ||||||||
| LastUpdateDate: | 12/23/2013 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X | 3305215A | IN | N | Behavioral Health & Social Service Providers | Social Worker | 1041C0700X | 34006718A | IN | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical | 101YA0400X | 87000624A | IN | N | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
ID Information
| ID | Type | State | Issuer | Description | 100462120 | 05 | IN | MEDICAID |