Provider Demographics
NPI:1215562806
Name:MOORE, MELLAKNESE (CPC-I, MS,ICADC, BSB)
Entity Type:Individual
Prefix:MS
First Name:MELLAKNESE
Middle Name:
Last Name:MOORE
Suffix:
Gender:F
Credentials:CPC-I, MS,ICADC, BSB
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9918 SHADOW GROVE AVE
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89148-4608
Mailing Address - Country:US
Mailing Address - Phone:702-935-0025
Mailing Address - Fax:702-935-0008
Practice Address - Street 1:3785 E SUNSET RD
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89120-6259
Practice Address - Country:US
Practice Address - Phone:702-482-9620
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-03-04
Last Update Date:2024-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR1501101YA0400X
NVC15180101YP2500X, 101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)