MEDICARE: MS. MELLAKNESE MOORE CPC-I, MS,ICADC, BSB

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YA0400X	Addiction (Substance Use Disorder) Counselor	1501	AR
2	101YP2500X	Professional Counselor	C15180	NV

General Provider Information

NPI Number	:	1215562806
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. MELLAKNESE MOORE CPC-I, MS,ICADC, BSB

Provider Business Mailing Address
First Line	:	9918 SHADOW GROVE AVE
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89148-4608
Country	:	US
Telephone Number	:	702-935-0025
Fax Number	:	702-935-0008

Provider Business Practice Location Address
First Line	:	3785 E SUNSET RD
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89120-6259
Country	:	US
Telephone Number	:	702-482-9620
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/04/2020
Last Update Date	:	02/12/2024

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