Provider Demographics
NPI:1457924052
Name:MOORE, NICOLE YVETTE (LCAS-A)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:YVETTE
Last Name:MOORE
Suffix:
Gender:
Credentials:LCAS-A
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3800 ARCO CORPORATE DR STE 150
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28273-4396
Mailing Address - Country:US
Mailing Address - Phone:336-662-7724
Mailing Address - Fax:
Practice Address - Street 1:3800 ARCO CORPORATE DR STE 150
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28273-4396
Practice Address - Country:US
Practice Address - Phone:336-662-7724
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-21
Last Update Date:2025-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCLCAS-30607101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Single Specialty