Provider Demographics
NPI:1851320295
Name:MOORE, CHEVOIS JOHNSON JR (LCSW)
Entity Type:Individual
Prefix:
First Name:CHEVOIS
Middle Name:JOHNSON
Last Name:MOORE
Suffix:JR
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:C
Other - Middle Name:JOHNSON
Other - Last Name:MOORE
Other - Suffix:JR
Other - Last Name Type:Other Name
Other - Credentials:LCSW
Mailing Address - Street 1:3828 PROVIDENCE RD
Mailing Address - Street 2:
Mailing Address - City:ROCKY MOUNT
Mailing Address - State:NC
Mailing Address - Zip Code:27803-1158
Mailing Address - Country:US
Mailing Address - Phone:252-451-1878
Mailing Address - Fax:
Practice Address - Street 1:3828 PROVIDENCE RD
Practice Address - Street 2:
Practice Address - City:ROCKY MOUNT
Practice Address - State:NC
Practice Address - Zip Code:27803-1158
Practice Address - Country:US
Practice Address - Phone:252-451-1878
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-30
Last Update Date:2013-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCC0013611041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6003504Medicaid
NC2865812Medicare ID - Type Unspecified
NC6003504Medicaid