Provider Demographics
NPI:1164759239
Name:MOORE, HATTIE DIONNE
Entity Type:Individual
Prefix:
First Name:HATTIE
Middle Name:DIONNE
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 1:11 SERENITY CT STE 303-C
Mailing Address - Street 2:
Mailing Address - City:DURHAM
Mailing Address - State:NC
Mailing Address - Zip Code:27704-5093
Mailing Address - Country:US
Mailing Address - Phone:252-336-3776
Mailing Address - Fax:
Practice Address - Street 1:3925 N DUKE ST STE 303-C
Practice Address - Street 2:
Practice Address - City:DURHAM
Practice Address - State:NC
Practice Address - Zip Code:27704-0049
Practice Address - Country:US
Practice Address - Phone:919-680-8833
Practice Address - Fax:919-682-7496
Is Sole Proprietor?:Yes
Enumeration Date:2009-11-11
Last Update Date:2020-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCC8040821041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical