Active NPI
Mary Lisa Moore
- Professional Counselor
- Fayetteville, NC
National Provider Identifier
1386743649
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Professional Counselor
- License
- 5216
- Practice address
- 2905 Breezewood Ave
Suite 101
Fayetteville, NC 28303 - Phone
- (910) 223-9927
- NPI assigned
- Sep 22, 2006
- Sex
- Female
- Sole proprietor
- No
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Professional Counselor | 101YP2500X | 5216 | NC | Primary |
Addresses
Primary practice location
2905 Breezewood Ave
Suite 101
Fayetteville, NC 28303
Mailing address
1415 West Hwy 54
Suite 101
Durham, NC 27707
Phone (919) 402-0120
Other identifiers 1
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 6103180 | Medicaid | NC |
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Not enrolled
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 5216 | NC | MD | Oral and Maxillofacial Surgery (Dentist) |
Practice roles
| Organization | Specialty | Status | New patients |
|---|---|---|---|
| Youth Development Corporation of America | Past | Accepting new patients |
Organizations & group practices 1
Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships and National Provider Directory roles.
-
- Community/Behavioral Health Agency
- Fayetteville, NC
- NPI 1942341177
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1158883200000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1183852800000",
"number": "1386743649",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "1415 WEST HWY 54",
"address_2": "SUITE 101",
"city": "DURHAM",
"state": "NC",
"postal_code": "27707",
"telephone_number": "919-402-0120"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "2905 BREEZEWOOD AVE",
"address_2": "SUITE 101",
"city": "FAYETTEVILLE",
"state": "NC",
"postal_code": "28303",
"telephone_number": "910-223-9927"
}
],
"practiceLocations": [],
"basic": {
"last_name": "MOORE",
"first_name": "MARY",
"middle_name": "LISA",
"sole_proprietor": "NO",
"sex": "F",
"enumeration_date": "2006-09-22",
"last_updated": "2007-07-08",
"status": "A"
},
"taxonomies": [
{
"code": "101YP2500X",
"taxonomy_group": "",
"desc": "Counselor, Professional",
"state": "NC",
"license": "5216",
"primary": true
}
],
"identifiers": [
{
"code": "05",
"desc": "MEDICAID",
"issuer": null,
"identifier": "6103180",
"state": "NC"
}
],
"endpoints": [],
"other_names": []
}Other providers in Fayetteville, NC
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jul 8, 2007; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.