Basic Information
Provider Information
NPI: 1003152596
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: MOORE
FirstName: THELMA
MiddleName:  
NamePrefix:  
NameSuffix:  
Credential: LCSW
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 250 N SHADELAND AVE
Address2: SUITE 130
City: INDIANAPOLIS
State: IN
PostalCode: 462194959
CountryCode: US
TelephoneNumber: 3179630954
FaxNumber: 3179624343
Practice Location
Address1: 355 W. 16TH ST.
Address2: STE. 3200
City: INDIANAPOLIS
State: IN
PostalCode: 462022207
CountryCode: US
TelephoneNumber: 3179637407
FaxNumber: 3179637533
Other Information
ProviderEnumerationDate: 01/02/2013
LastUpdateDate: 10/03/2013
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: F
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: N
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
1041C0700X34006639AINY Behavioral Health & Social Service ProvidersSocial WorkerClinical

No ID Information.


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