Provider Demographics
NPI:1104094978
Name:MOORE, SOPHIA
Entity type:Individual
Prefix:
First Name:SOPHIA
Middle Name:
Last Name:MOORE
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:168 BENNINGTON DR
Mailing Address - Street 2:
Mailing Address - City:RAEFORD
Mailing Address - State:NC
Mailing Address - Zip Code:28376-6559
Mailing Address - Country:US
Mailing Address - Phone:910-263-6219
Mailing Address - Fax:
Practice Address - Street 1:168 BENNINGTON DR
Practice Address - Street 2:
Practice Address - City:RAEFORD
Practice Address - State:NC
Practice Address - Zip Code:28376-6559
Practice Address - Country:US
Practice Address - Phone:910-263-6219
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-02-14
Last Update Date:2025-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC232101YP2500X
DCPRC14509101YP2500X
VA0701006133101YP2500X
NC24951-A101YA0400X
NCS6959101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)