Provider Demographics
NPI:1639369556
Name:MOORE, JOHN DAVID II (LCPC)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:DAVID
Last Name:MOORE
Suffix:II
Gender:M
Credentials:LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2514 S CROATAN HWY
Mailing Address - Street 2:
Mailing Address - City:NAGS HEAD
Mailing Address - State:NC
Mailing Address - Zip Code:27959-9016
Mailing Address - Country:US
Mailing Address - Phone:140-675-0417
Mailing Address - Fax:
Practice Address - Street 1:2514 S CROATAN HWY
Practice Address - Street 2:
Practice Address - City:NAGS HEAD
Practice Address - State:NC
Practice Address - Zip Code:27959-9016
Practice Address - Country:US
Practice Address - Phone:140-675-0417
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-07-26
Last Update Date:2012-02-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT1326 LCPC101YP2500X
NC9119101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT0000744050OtherBLUE CROSS-SHIELD PROV #
NC1639369556Medicaid