Provider Demographics
NPI:1245276385
Name:MOOSE, MELISSA I (LC SW)
Entity type:Individual
Prefix:
First Name:MELISSA
Middle Name:I
Last Name:MOOSE
Suffix:
Gender:F
Credentials:LC SW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 4003
Mailing Address - Street 2:
Mailing Address - City:GASTONIA
Mailing Address - State:NC
Mailing Address - Zip Code:28054-0020
Mailing Address - Country:US
Mailing Address - Phone:704-865-3525
Mailing Address - Fax:704-865-3520
Practice Address - Street 1:917 1ST ST
Practice Address - Street 2:
Practice Address - City:SHELBY
Practice Address - State:NC
Practice Address - Zip Code:28150-3958
Practice Address - Country:US
Practice Address - Phone:704-476-4028
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCC0044261041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6106324Medicaid
NC14219OtherBCBS
NC188636OtherMEDCOST