Provider Demographics
NPI:1831241249
Name:MOORE, STANLEY GARDNER (LCSW)
Entity type:Individual
Prefix:MR
First Name:STANLEY
Middle Name:GARDNER
Last Name:MOORE
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9118 PARK GROVE ST
Mailing Address - Street 2:
Mailing Address - City:HUNTERSVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28078-5517
Mailing Address - Country:US
Mailing Address - Phone:704-948-9344
Mailing Address - Fax:
Practice Address - Street 1:9118 PARK GROVE ST
Practice Address - Street 2:
Practice Address - City:HUNTERSVILLE
Practice Address - State:NC
Practice Address - Zip Code:28078-5517
Practice Address - Country:US
Practice Address - Phone:704-948-9344
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-17
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCC0035811041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6106241Medicaid