Provider Demographics
NPI:1467231902
Name:MOORE, MELISSA RAENAE (CADC)
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:RAENAE
Last Name:MOORE
Suffix:
Gender:F
Credentials:CADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4 GILLIAM ST
Mailing Address - Street 2:
Mailing Address - City:CORBIN
Mailing Address - State:KY
Mailing Address - Zip Code:40701-1520
Mailing Address - Country:US
Mailing Address - Phone:606-401-7647
Mailing Address - Fax:
Practice Address - Street 1:1501 S MAIN ST STE H
Practice Address - Street 2:
Practice Address - City:LONDON
Practice Address - State:KY
Practice Address - Zip Code:40741-2091
Practice Address - Country:US
Practice Address - Phone:606-393-6695
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-09-25
Last Update Date:2023-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY275318101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)