Provider Demographics
NPI:1003467796
Name:MOORE, LATISE
Entity Type:Individual
Prefix:MRS
First Name:LATISE
Middle Name:
Last Name:MOORE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9336 KINGS PARADE BLVD APT 3225
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28273-5858
Mailing Address - Country:US
Mailing Address - Phone:757-535-6678
Mailing Address - Fax:
Practice Address - Street 1:9336 KINGS PARADE BLVD APT 3225
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28273-5858
Practice Address - Country:US
Practice Address - Phone:757-535-6678
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-09-24
Last Update Date:2019-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCC0121781041C0700X
VA09040107311041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical