Provider Demographics
NPI:1992860670
Name:MOORE, LATISHA (BS)
Entity Type:Individual
Prefix:MRS
First Name:LATISHA
Middle Name:
Last Name:MOORE
Suffix:
Gender:F
Credentials:BS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:139 W 3RD STREET
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:27889-4970
Mailing Address - Country:US
Mailing Address - Phone:252-940-7260
Mailing Address - Fax:252-940-7261
Practice Address - Street 1:139 W 3RD STREET
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:NC
Practice Address - Zip Code:27889-3565
Practice Address - Country:US
Practice Address - Phone:252-940-7260
Practice Address - Fax:252-940-7261
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-24
Last Update Date:2008-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X, 171M00000X
NC251B00000X
NCMHL-007-062320600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251B00000XAgenciesCase Management
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
No320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities