Provider Demographics
NPI:1750129813
Name:MOORE, MARY KATHERINE (LCMHCA, NCC)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:KATHERINE
Last Name:MOORE
Suffix:
Gender:F
Credentials:LCMHCA, NCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:EVOLVE PSYCH GROUP, PLLC 10706 SIKES PLACE, SUITE 275
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28277
Mailing Address - Country:US
Mailing Address - Phone:704-577-4071
Mailing Address - Fax:
Practice Address - Street 1:EVOLVE PSYCH GROUP, PLLC 10706 SIKES PLACE, SUITE 275
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28277
Practice Address - Country:US
Practice Address - Phone:704-577-4071
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-07-15
Last Update Date:2024-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCA20249101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health