Healthcare Provider Details

I. General information

NPI: 1427945518
Provider Name (Legal Business Name): KAILO'S MENTAL RETREAT
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/20/2025
Last Update Date: 06/20/2025
Certification Date: 06/20/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

748 ADDINGTON DR
WINTERVILLE NC
28590-7102
US

IV. Provider business mailing address

748 ADDINGTON DR
WINTERVILLE NC
28590-7102
US

V. Phone/Fax

Practice location:
  • Phone: 252-414-3318
  • Fax: 252-677-6551
Mailing address:
  • Phone: 252-414-3318
  • Fax: 252-677-6551

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: LISA MICHELLE MOORE
Title or Position: MSN, PMHNP-C
Credential: PMHNP-C
Phone: 252-414-3318