=====================================================
General NPI Number Information
=====================================================
NPI Number | 1285333526
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | LISA MARIE MOORE NC LMBT
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/27/2023
-----------------------------------------------------
Last Update Date | 02/27/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 32 BROADWAY ST STE 240
-----------------------------------------------------
City | ASHEVILLE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28801-2959
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 704-254-2759
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 36 MOUNTAIN BROOK DR
-----------------------------------------------------
City | CANDLER
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28715-9405
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 704-254-2759
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225700000X
-----------------------------------------------------
Taxonomy Name | Massage Therapist
-----------------------------------------------------
License Number | 18558
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------