Provider Demographics
NPI:1558614677
Name:MOORE, TRACY J (LCAS-A)
Entity Type:Individual
Prefix:
First Name:TRACY
Middle Name:J
Last Name:MOORE
Suffix:
Gender:F
Credentials:LCAS-A
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5500 EXECUTIVE CENTER DR
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28212-8856
Mailing Address - Country:US
Mailing Address - Phone:704-537-5760
Mailing Address - Fax:
Practice Address - Street 1:5500 EXECUTIVE CENTER DR
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28212-8856
Practice Address - Country:US
Practice Address - Phone:704-537-5760
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-10-26
Last Update Date:2016-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCLCAS-15519101YM0800X, 171M00000X, 172V00000X, 101YA0400X, 101Y00000X
NCP0074031041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
No172V00000XOther Service ProvidersCommunity Health Worker
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101Y00000XBehavioral Health & Social Service ProvidersCounselor