Provider Demographics
NPI:1265251631
Name:MOORE, KYLE (LCSW, LCAS, MSW)
Entity type:Individual
Prefix:
First Name:KYLE
Middle Name:
Last Name:MOORE
Suffix:
Gender:M
Credentials:LCSW, LCAS, MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5140 DUNSTAN RD
Mailing Address - Street 2:
Mailing Address - City:GREENSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27405-9565
Mailing Address - Country:US
Mailing Address - Phone:336-553-6635
Mailing Address - Fax:
Practice Address - Street 1:5140 DUNSTAN RD
Practice Address - Street 2:
Practice Address - City:GREENSBORO
Practice Address - State:NC
Practice Address - Zip Code:27405-9565
Practice Address - Country:US
Practice Address - Phone:336-553-6635
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-10-03
Last Update Date:2024-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCC0164061041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical