Provider Demographics
NPI:1073756540
Name:MOORE, MARY B (LCSW)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:B
Last Name:MOORE
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6115 PARK SOUTH DR
Mailing Address - Street 2:SUITE 130
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28210-3269
Mailing Address - Country:US
Mailing Address - Phone:704-552-0116
Mailing Address - Fax:704-552-7550
Practice Address - Street 1:6115 PARK SOUTH DR
Practice Address - Street 2:SUITE 130
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28210-3269
Practice Address - Country:US
Practice Address - Phone:704-552-0116
Practice Address - Fax:704-552-7550
Is Sole Proprietor?:No
Enumeration Date:2009-04-14
Last Update Date:2009-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCC0063711041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical