Provider Demographics
NPI:1407263593
Name:MOORE, KENETRA DEVONNE (LCMHC, LCAS, CCS)
Entity Type:Individual
Prefix:
First Name:KENETRA
Middle Name:DEVONNE
Last Name:MOORE
Suffix:
Gender:F
Credentials:LCMHC, LCAS, CCS
Other - Prefix:
Other - First Name:K
Other - Middle Name:DEVONNE
Other - Last Name:MOORE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LCAS, LCMHC,CCS
Mailing Address - Street 1:1012 ALLEN ST
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28205-2750
Mailing Address - Country:US
Mailing Address - Phone:704-900-1850
Mailing Address - Fax:
Practice Address - Street 1:3301 TENNESSEE AVE
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28216-4077
Practice Address - Country:US
Practice Address - Phone:704-900-1850
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-07-21
Last Update Date:2024-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC20215101YA0400X
NC15759101YM0800X
101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC21286Medicaid