Provider Demographics
NPI:1386743649
Name:MOORE, MARY LISA
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:LISA
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 1:1415 WEST HWY 54
Mailing Address - Street 2:SUITE 101
Mailing Address - City:DURHAM
Mailing Address - State:NC
Mailing Address - Zip Code:27707
Mailing Address - Country:US
Mailing Address - Phone:919-402-0120
Mailing Address - Fax:
Practice Address - Street 1:2905 BREEZEWOOD AVE
Practice Address - Street 2:SUITE 101
Practice Address - City:FAYETTEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28303
Practice Address - Country:US
Practice Address - Phone:910-223-9927
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC5216101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6103180Medicaid