Provider Demographics
NPI:1144686593
Name:MOORE, AMBER (LCAS, SAP)
Entity type:Individual
Prefix:
First Name:AMBER
Middle Name:
Last Name:MOORE
Suffix:
Gender:F
Credentials:LCAS, SAP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:822 OLD WINSTON RD
Mailing Address - Street 2:SUITE 5
Mailing Address - City:KERNERSVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:27284-7106
Mailing Address - Country:US
Mailing Address - Phone:336-558-0219
Mailing Address - Fax:
Practice Address - Street 1:822 OLD WINSTON RD
Practice Address - Street 2:SUITE 5
Practice Address - City:KERNERSVILLE
Practice Address - State:NC
Practice Address - Zip Code:27284
Practice Address - Country:US
Practice Address - Phone:336-558-0219
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-01-14
Last Update Date:2017-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101Y00000X
NC22505101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101Y00000XBehavioral Health & Social Service ProvidersCounselor