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Individual
NICOLETTE STATON MOON
Active
Individual
NICOLETTE STATON MOON
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
LCSW
Taxonomy
Speciality
Code
Description
License number
State
1041C0700X
Clinical Social Worker
Primary
0904003308
VA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
205825
ANTHEM
VA
01
—
2169372
MAMSI
VA
01
—
263166-000
MAGELLAN
VA
01
—
4945131
VIRGINIA PREMIER
VA
01
—
O89418
OPTIMA
VA
Enumeration date
02/19/2007
Last updated
09/26/2008
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