Healthcare Provider Details

I. General information

NPI: 1558829234
Provider Name (Legal Business Name): MATTHEW MOORE LICSW, LCSW, LISW-CP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/12/2019
Last Update Date: 08/07/2026
Certification Date: 08/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2006 S MAIN ST STE 204
WAKE FOREST NC
27587-9391
US

IV. Provider business mailing address

2006 S MAIN ST STE 204
WAKE FOREST NC
27587-9391
US

V. Phone/Fax

Practice location:
  • Phone: 360-844-0462
  • Fax:
Mailing address:
  • Phone: 360-844-0462
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLW61418510
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number14298209-3501
License Number StateUT
# 3
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberC017890
License Number StateNC
# 4
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number17200
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: