Provider Demographics
NPI:1376059840
Name:MOORE, DANIELLE CLARK (MS, CRC, LPCA)
Entity Type:Individual
Prefix:MRS
First Name:DANIELLE
Middle Name:CLARK
Last Name:MOORE
Suffix:
Gender:F
Credentials:MS, CRC, LPCA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5510 BROOKFIELD RIDGE DR
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27105-1757
Mailing Address - Country:US
Mailing Address - Phone:336-391-1601
Mailing Address - Fax:
Practice Address - Street 1:500 W 4TH ST STE 203
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27101-2782
Practice Address - Country:US
Practice Address - Phone:336-391-1601
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-12-20
Last Update Date:2017-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCA13571101Y00000X
NC00282458225C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225C00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Counselor
No101Y00000XBehavioral Health & Social Service ProvidersCounselor