Provider Demographics
NPI:1336529957
Name:MOORE, TOMEKO
Entity Type:Individual
Prefix:
First Name:TOMEKO
Middle Name:
Last Name:MOORE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4912 LEGACY DR
Mailing Address - Street 2:
Mailing Address - City:COLFAX
Mailing Address - State:NC
Mailing Address - Zip Code:27235-9436
Mailing Address - Country:US
Mailing Address - Phone:336-285-7449
Mailing Address - Fax:
Practice Address - Street 1:5 CENTERVIEW DR
Practice Address - Street 2:
Practice Address - City:GREENSBORO
Practice Address - State:NC
Practice Address - Zip Code:27407-3724
Practice Address - Country:US
Practice Address - Phone:336-887-0708
Practice Address - Fax:336-887-1085
Is Sole Proprietor?:Yes
Enumeration Date:2015-06-09
Last Update Date:2015-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCLCAS-21233101YA0400X
NCP009579104100000X, 1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No104100000XBehavioral Health & Social Service ProvidersSocial Worker