Provider Demographics
NPI:1952967457
Name:MOORE, KEYANA
Entity Type:Individual
Prefix:
First Name:KEYANA
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 1:12419 OLD TIMBER RD
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28269-8709
Mailing Address - Country:US
Mailing Address - Phone:980-219-3318
Mailing Address - Fax:
Practice Address - Street 1:12419 OLD TIMBER RD
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28269-8709
Practice Address - Country:US
Practice Address - Phone:980-219-3318
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-05-10
Last Update Date:2019-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker