Provider Demographics
NPI:1346452620
Name:MOORE, CHARLES MAURICE (MA,LPC,LCAS,NCC,ICAA)
Entity Type:Individual
Prefix:MR
First Name:CHARLES
Middle Name:MAURICE
Last Name:MOORE
Suffix:
Gender:M
Credentials:MA,LPC,LCAS,NCC,ICAA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1516 KELLY CT
Mailing Address - Street 2:
Mailing Address - City:CONOVER
Mailing Address - State:NC
Mailing Address - Zip Code:28613-7801
Mailing Address - Country:US
Mailing Address - Phone:828-441-0115
Mailing Address - Fax:
Practice Address - Street 1:1516 KELLY CT
Practice Address - Street 2:
Practice Address - City:CONOVER
Practice Address - State:NC
Practice Address - Zip Code:28613-7801
Practice Address - Country:US
Practice Address - Phone:828-441-0115
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC386101YA0400X
NC1086101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Not Answered101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6103410Medicaid