Provider Demographics
NPI:1033531900
Name:MOULTRIE, KELLY
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:MOULTRIE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2715 COLONIAL DR
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29203-6818
Mailing Address - Country:US
Mailing Address - Phone:803-783-0303
Mailing Address - Fax:803-783-0955
Practice Address - Street 1:1850 PINEVIEW DR
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29209-5085
Practice Address - Country:US
Practice Address - Phone:803-783-0303
Practice Address - Fax:803-783-0955
Is Sole Proprietor?:No
Enumeration Date:2014-01-13
Last Update Date:2014-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional