Provider Demographics
NPI:1376140970
Name:MOORE, KENISHA NICOLE
Entity Type:Individual
Prefix:
First Name:KENISHA
Middle Name:NICOLE
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 1:5967 PARSONS LN
Mailing Address - Street 2:
Mailing Address - City:KING GEORGE
Mailing Address - State:VA
Mailing Address - Zip Code:22485-2434
Mailing Address - Country:US
Mailing Address - Phone:540-413-6247
Mailing Address - Fax:
Practice Address - Street 1:8221 WILLOW OAKS CORPORATE DR
Practice Address - Street 2:
Practice Address - City:FAIRFAX
Practice Address - State:VA
Practice Address - Zip Code:22031-4512
Practice Address - Country:US
Practice Address - Phone:703-599-3000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-10-06
Last Update Date:2024-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
01041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical