1457415853 NPI number — DR. CASSANDRA JO MOORE PHD, MA, LPC, LPC/S

Table of content: DR. CASSANDRA JO MOORE PHD, MA, LPC, LPC/S (NPI 1457415853)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1457415853 NPI number — DR. CASSANDRA JO MOORE PHD, MA, LPC, LPC/S

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MOORE
Provider First Name:
CASSANDRA
Provider Middle Name:
JO
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
PHD, MA, LPC, LPC/S
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1457415853
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/09/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3122 SAVANNAH HWY
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
NORTH
Provider Business Mailing Address State Name:
SC
Provider Business Mailing Address Postal Code:
29112-8165
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
803-604-6253
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3122 SAVANNAH HWY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
NORTH
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29112-8165
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
803-604-6253
Provider Business Practice Location Address Fax Number:
855-397-9171
Provider Enumeration Date:
12/20/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 101YM0800X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 101YP2500X , with the licence number: 5056 , registered in the state of SC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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