Healthcare Provider Details

I. General information

NPI: 1265533368
Provider Name (Legal Business Name): ANGELA ELLEN MOORE LCMHCS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: ANGELA MARIE ELLEN LPCS

II. Dates (important events)

Enumeration Date: 09/25/2006
Last Update Date: 10/31/2024
Certification Date: 10/31/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6781 CAMDEN RD
FAYETTEVILLE NC
28306-7223
US

IV. Provider business mailing address

1101 W 40TH ST UNIT 2225
CHATTANOOGA TN
37409-1379
US

V. Phone/Fax

Practice location:
  • Phone: 877-358-2998
  • Fax: 423-405-6346
Mailing address:
  • Phone: 877-358-2998
  • Fax: 423-405-6346

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberS5187
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License NumberS5187
License Number StateNC
# 3
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberS5187
License Number StateNC
# 4
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License NumberS5187
License Number StateNC
# 5
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberS5187
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: