Provider Demographics
NPI:1255865440
Name:MOORE, NATASHA M D (MSW, LCSW-A)
Entity Type:Individual
Prefix:
First Name:NATASHA
Middle Name:M D
Last Name:MOORE
Suffix:
Gender:F
Credentials:MSW, LCSW-A
Other - Prefix:
Other - First Name:NATASHA
Other - Middle Name:MARIE
Other - Last Name:DAVIS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MSW, LGSW
Mailing Address - Street 1:2543 RAVENHILL DR STE B
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28303-5459
Mailing Address - Country:US
Mailing Address - Phone:910-339-1928
Mailing Address - Fax:910-339-4650
Practice Address - Street 1:2543 RAVENHILL DR STE B
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28303-5459
Practice Address - Country:US
Practice Address - Phone:910-339-1928
Practice Address - Fax:910-339-4650
Is Sole Proprietor?:Yes
Enumeration Date:2017-04-14
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVBP00944949104100000X
NCP0114271041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker