Provider Demographics
NPI:1649994906
Name:SISTRUNK MOORE, ZELLUA (MSW, LCSWA)
Entity type:Individual
Prefix:
First Name:ZELLUA
Middle Name:
Last Name:SISTRUNK MOORE
Suffix:
Gender:F
Credentials:MSW, LCSWA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6012 BAYFIELD PKWY # 386
Mailing Address - Street 2:
Mailing Address - City:CONCORD
Mailing Address - State:NC
Mailing Address - Zip Code:28027-7597
Mailing Address - Country:US
Mailing Address - Phone:980-271-4628
Mailing Address - Fax:
Practice Address - Street 1:303 TRILLIUM ST NW
Practice Address - Street 2:
Practice Address - City:CONCORD
Practice Address - State:NC
Practice Address - Zip Code:28027-7206
Practice Address - Country:US
Practice Address - Phone:980-271-4628
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-09-30
Last Update Date:2022-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCP0179581041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
92-0482059OtherIRS