Provider Demographics
NPI:1134322589
Name:MOORE, KELLY CONROY (PHD, LICSW)
Entity Type:Individual
Prefix:DR
First Name:KELLY
Middle Name:CONROY
Last Name:MOORE
Suffix:
Gender:F
Credentials:PHD, LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4126 117TH AVE NE
Mailing Address - Street 2:
Mailing Address - City:KIRKLAND
Mailing Address - State:WA
Mailing Address - Zip Code:98033-8744
Mailing Address - Country:US
Mailing Address - Phone:425-576-0181
Mailing Address - Fax:
Practice Address - Street 1:8290 165TH AVE NE
Practice Address - Street 2:
Practice Address - City:REDMOND
Practice Address - State:WA
Practice Address - Zip Code:98052-3948
Practice Address - Country:US
Practice Address - Phone:425-869-2644
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALW000094241041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical