Provider Demographics
NPI:1407994841
Name:RAINES, MARILYN MOORER (LCSW)
Entity Type:Individual
Prefix:MRS
First Name:MARILYN
Middle Name:MOORER
Last Name:RAINES
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6515 BARRY WHITAKER RD
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28227-0414
Mailing Address - Country:US
Mailing Address - Phone:704-573-8984
Mailing Address - Fax:
Practice Address - Street 1:1505 E 4TH ST
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28204-3223
Practice Address - Country:US
Practice Address - Phone:704-905-9731
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-01
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCC0005791041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6003073Medicaid