Provider Demographics
NPI:1790093730
Name:MOORE, MELODY LYNN (LCSW, MS, MPAP)
Entity Type:Individual
Prefix:
First Name:MELODY
Middle Name:LYNN
Last Name:MOORE
Suffix:
Gender:F
Credentials:LCSW, MS, MPAP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:380 KNOLLWOOD ST, STE H, PMB 115
Mailing Address - Street 2:
Mailing Address - City:WINSTON-SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27103-5859
Mailing Address - Country:US
Mailing Address - Phone:336-794-6811
Mailing Address - Fax:
Practice Address - Street 1:1399 ASHLEY BROOK LANE SUITE 100
Practice Address - Street 2:
Practice Address - City:WINSTON-SALEM
Practice Address - State:NC
Practice Address - Zip Code:27103
Practice Address - Country:US
Practice Address - Phone:336-794-6811
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-09-23
Last Update Date:2024-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCC0069931041C0700X
NC0010-13458363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical