Healthcare Provider Details

I. General information

NPI: 1861022857
Provider Name (Legal Business Name): GWENDOLYN MOORE NCC, LCMHC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/19/2020
Last Update Date: 04/23/2025
Certification Date: 04/23/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1633 NEW GARDEN RD UNIT 211
GREENSBORO NC
27410-2001
US

IV. Provider business mailing address

1633 NEW GARDEN RD UNIT 211
GREENSBORO NC
27410-2001
US

V. Phone/Fax

Practice location:
  • Phone: 336-402-6688
  • Fax: 336-458-9696
Mailing address:
  • Phone: 336-402-6688
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number15386
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number15386
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: