Individual
MARY LISA MOORE
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Contact information
Practice address
2905 BREEZEWOOD AVE, SUITE 101, FAYETTEVILLE, NC 28303
(910) 223-9927
Mailing address
1415 WEST HWY 54, SUITE 101, DURHAM, NC 27707
(919) 402-0120
Taxonomy
Speciality
Code
Description
License number
State
101YP2500X
Professional Counselor
Primary
5216
NC
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
6103180
—
NC
Enumeration date
09/22/2006
Last updated
07/08/2007
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