Provider Demographics
NPI:1114453495
Name:MOORE, AMANDA MICHELLE
Entity Type:Individual
Prefix:MRS
First Name:AMANDA
Middle Name:MICHELLE
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 1:111 MACKENAN DR
Mailing Address - Street 2:
Mailing Address - City:CARY
Mailing Address - State:NC
Mailing Address - Zip Code:27511-7903
Mailing Address - Country:US
Mailing Address - Phone:919-371-2848
Mailing Address - Fax:
Practice Address - Street 1:9305 MONROE RD STE L
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28270-1490
Practice Address - Country:US
Practice Address - Phone:980-819-0010
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-05-05
Last Update Date:2017-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
1-17-25019103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst