Healthcare Provider Details

I. General information

NPI: 1013269422
Provider Name (Legal Business Name): NICHOLE MOORE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/09/2012
Last Update Date: 10/09/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3511 W MARKET ST STE. B
GREENSBORO NC
27403-4443
US

IV. Provider business mailing address

604 PEACH ORCHARD DR
BROWNS SUMMIT NC
27214-9498
US

V. Phone/Fax

Practice location:
  • Phone: 336-294-3338
  • Fax: 336-294-6696
Mailing address:
  • Phone: 336-543-4381
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code222Q00000X
TaxonomyDevelopmental Therapist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: