Basic Information
| Provider Information | |||||||||
| NPI: | 1497385595 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MOORE | ||||||||
| FirstName: | AEREIL | ||||||||
| MiddleName: | DELICIA | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MS, LCMHCA, LCAS | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | PEA | ||||||||
| OtherFirstName: | AEREIL | ||||||||
| OtherMiddleName: | DELICIA | ||||||||
| OtherNamePrefix: | MS. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 284 EXECUTIVE PARK DR STE 100 | ||||||||
| Address2: | |||||||||
| City: | CONCORD | ||||||||
| State: | NC | ||||||||
| PostalCode: | 280251833 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7049391173 | ||||||||
| FaxNumber: | 7049391173 | ||||||||
| Practice Location | |||||||||
| Address1: | 650 HIGHLAND AVE | ||||||||
| Address2: | |||||||||
| City: | WINSTON SALEM | ||||||||
| State: | NC | ||||||||
| PostalCode: | 271014304 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3366078523 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/17/2020 | ||||||||
| LastUpdateDate: | 01/11/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 01/11/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | 25198 | NC | N | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 101YP2500X | A14537 | NC | Y | Behavioral Health & Social Service Providers | Counselor | Professional |
No ID Information.