Provider Demographics
NPI:1700362779
Name:MOORE, JOHNICE AEIDA YVETTE
Entity Type:Individual
Prefix:
First Name:JOHNICE
Middle Name:AEIDA YVETTE
Last Name:MOORE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:210 STREAMS WAY
Mailing Address - Street 2:
Mailing Address - City:ANDERSON
Mailing Address - State:SC
Mailing Address - Zip Code:29625-5148
Mailing Address - Country:US
Mailing Address - Phone:919-475-9375
Mailing Address - Fax:
Practice Address - Street 1:226 MCGEE RD
Practice Address - Street 2:
Practice Address - City:ANDERSON
Practice Address - State:SC
Practice Address - Zip Code:29625-2104
Practice Address - Country:US
Practice Address - Phone:864-260-4168
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-12
Last Update Date:2018-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC11953104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker