Provider Demographics
NPI:1609048065
Name:MOORE, KATHERINE A (LCSW)
Entity Type:Individual
Prefix:MRS
First Name:KATHERINE
Middle Name:A
Last Name:MOORE
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:MS
Other - First Name:KATHERINE
Other - Middle Name:A
Other - Last Name:FARRELL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LCSW
Mailing Address - Street 1:PO BOX 581
Mailing Address - Street 2:
Mailing Address - City:CORNELIUS
Mailing Address - State:NC
Mailing Address - Zip Code:28031-0581
Mailing Address - Country:US
Mailing Address - Phone:704-928-8266
Mailing Address - Fax:
Practice Address - Street 1:2329 WEDGEWOOD DR
Practice Address - Street 2:
Practice Address - City:MATTHEWS
Practice Address - State:NC
Practice Address - Zip Code:28104-9253
Practice Address - Country:US
Practice Address - Phone:704-928-8266
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-03-26
Last Update Date:2015-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCC0067261041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6007487Medicaid