Healthcare Provider Details

I. General information

NPI: 1053234450
Provider Name (Legal Business Name): SHANE MOORE LCPC-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/03/2026
Last Update Date: 08/03/2026
Certification Date: 08/03/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4 SCAMMON ST STE 19-305
SACO ME
04072-5121
US

IV. Provider business mailing address

4 SCAMMAN ST SUITE 19-305
SACO ME
04072-5121
US

V. Phone/Fax

Practice location:
  • Phone: 617-657-9460
  • Fax:
Mailing address:
  • Phone: 617-657-9460
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberXL8807
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: