Basic Information
| Provider Information | |||||||||
| NPI: | 1457831901 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MOODY | ||||||||
| FirstName: | NICOLE | ||||||||
| MiddleName: | |||||||||
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| Credential: | LMFT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 620 ERIE BLVD W STE 208 | ||||||||
| Address2: | |||||||||
| City: | SYRACUSE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 132042457 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3154727363 | ||||||||
| FaxNumber: | 3157012368 | ||||||||
| Practice Location | |||||||||
| Address1: | 620 ERIE BLVD W STE 208 | ||||||||
| Address2: | |||||||||
| City: | SYRACUSE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 132042457 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3154727363 | ||||||||
| FaxNumber: | 3157012368 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/15/2018 | ||||||||
| LastUpdateDate: | 02/06/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 02/06/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101Y00000X | P12131 | NY | N | Behavioral Health & Social Service Providers | Counselor | 106H00000X | 001645 | NY | Y | Behavioral Health & Social Service Providers | Marriage & Family Therapist |
ID Information
| ID | Type | State | Issuer | Description | 1336163963 | 05 | NY | MEDICAID |