Provider Demographics
NPI:1801544242
Name:MOORE, NYDESHA VINSHAY
Entity type:Individual
Prefix:
First Name:NYDESHA
Middle Name:VINSHAY
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:PO BOX 31062
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:27833-1062
Mailing Address - Country:US
Mailing Address - Phone:252-367-3587
Mailing Address - Fax:252-371-1655
Practice Address - Street 1:3106 S MEMORIAL DR STE B
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:NC
Practice Address - Zip Code:27834-6765
Practice Address - Country:US
Practice Address - Phone:252-916-6048
Practice Address - Fax:252-371-1655
Is Sole Proprietor?:No
Enumeration Date:2022-03-15
Last Update Date:2022-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCP0173341041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical