MEDICARE: GWENDOLYN MOORE NCC, LCMHC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YP2500X	Professional Counselor	15386	NC
2	101YM0800X	Mental Health Counselor	15386	NC

General Provider Information

NPI Number	:	1861022857
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	GWENDOLYN MOORE NCC, LCMHC

Provider Business Mailing Address
First Line	:	1633 NEW GARDEN RD UNIT 211
Second Line	:
City	:	GREENSBORO
State	:	NC
Zip	:	27410-2001
Country	:	US
Telephone Number	:	336-402-6688
Fax Number	:

Provider Business Practice Location Address
First Line	:	1633 NEW GARDEN RD UNIT 211
Second Line	:
City	:	GREENSBORO
State	:	NC
Zip	:	27410-2001
Country	:	US
Telephone Number	:	336-402-6688
Fax Number	:	336-458-9696

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/19/2020
Last Update Date	:	04/23/2025

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