Healthcare Provider Details

I. General information

NPI: 1154382349
Provider Name (Legal Business Name): LYDIA HALSEY MOORE MSW, LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 03/29/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8401 MEDICAL PLAZA DR SUITE 350
CHARLOTTE NC
28262-8797
US

IV. Provider business mailing address

5154 LINCREST PL
CHARLOTTE NC
28211-4109
US

V. Phone/Fax

Practice location:
  • Phone: 704-547-0020
  • Fax: 704-594-6041
Mailing address:
  • Phone: 704-547-0020
  • Fax: 704-594-9759

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberC004980
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: