Provider Demographics
NPI:1336543776
Name:MOORE, KEISHA MCCLEESE (LPC)
Entity Type:Individual
Prefix:MRS
First Name:KEISHA
Middle Name:MCCLEESE
Last Name:MOORE
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1052 GLENMONT RD
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27107-1561
Mailing Address - Country:US
Mailing Address - Phone:336-978-4911
Mailing Address - Fax:
Practice Address - Street 1:2962 YOUTH UNLIMITED DR
Practice Address - Street 2:
Practice Address - City:SOPHIA
Practice Address - State:NC
Practice Address - Zip Code:27350-8481
Practice Address - Country:US
Practice Address - Phone:336-861-9243
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-10-14
Last Update Date:2019-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCA10870101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional