1346655891 NPI number — LISETTE JENEE-MOORE DEESE LCSWA, LCAS

Table of content: LISETTE JENEE-MOORE DEESE LCSWA, LCAS (NPI 1346655891)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1346655891 NPI number — LISETTE JENEE-MOORE DEESE LCSWA, LCAS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DEESE
Provider First Name:
LISETTE
Provider Middle Name:
JENEE-MOORE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
LCSWA, LCAS
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:
1346655891
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/07/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4542 RAEFORD RD STE A11
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FAYETTEVILLE
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
28304-0076
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
919-418-9562
Provider Business Mailing Address Fax Number:
800-799-3010

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
10130 PERIMETER PKWY
Provider Second Line Business Practice Location Address:
STE 200
Provider Business Practice Location Address City Name:
CHARLOTTE
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
28216-2447
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
888-849-7379
Provider Business Practice Location Address Fax Number:
855-857-7333
Provider Enumeration Date:
06/24/2014

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: 101YA0400X , with the licence number:  3301 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 1041C0700X , with the licence number: C010049 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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