Provider Demographics
NPI:1124521307
Name:MOORE, WILLIAM KENNETH III (COUNSELOR II, MA)
Entity type:Individual
Prefix:MR
First Name:WILLIAM
Middle Name:KENNETH
Last Name:MOORE
Suffix:III
Gender:M
Credentials:COUNSELOR II, MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Mailing Address - Street 1:187 W BROAD ST
Mailing Address - Street 2:
Mailing Address - City:SPARTANBURG
Mailing Address - State:SC
Mailing Address - Zip Code:29306-3234
Mailing Address - Country:US
Mailing Address - Phone:864-582-7588
Mailing Address - Fax:864-582-0431
Practice Address - Street 1:187 W BROAD ST
Practice Address - Street 2:
Practice Address - City:SPARTANBURG
Practice Address - State:SC
Practice Address - Zip Code:29306-3234
Practice Address - Country:US
Practice Address - Phone:864-582-7588
Practice Address - Fax:864-582-0431
Is Sole Proprietor?:No
Enumeration Date:2018-03-14
Last Update Date:2018-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC05Medicaid