Provider Demographics
NPI:1467663013
Name:MOONE, WESLEY JAY (LPA)
Entity type:Individual
Prefix:MR
First Name:WESLEY
Middle Name:JAY
Last Name:MOONE
Suffix:
Gender:M
Credentials:LPA
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:5509 MONROE RD
Mailing Address - Street 2:SUITE 203
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28212-5503
Mailing Address - Country:US
Mailing Address - Phone:704-535-4143
Mailing Address - Fax:704-568-8927
Practice Address - Street 1:5509 MONROE RD
Practice Address - Street 2:SUITE 203
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28212-5503
Practice Address - Country:US
Practice Address - Phone:704-535-4143
Practice Address - Fax:704-568-8927
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-25
Last Update Date:2013-07-24
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NC1437103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6107231Medicaid