Provider Demographics
NPI:1174652762
Name:MOORE, KELLY L (BSW)
Entity Type:Individual
Prefix:MS
First Name:KELLY
Middle Name:L
Last Name:MOORE
Suffix:
Gender:F
Credentials:BSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:531 16TH ST
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92101-7609
Mailing Address - Country:US
Mailing Address - Phone:619-233-3432
Mailing Address - Fax:619-233-7022
Practice Address - Street 1:531 16TH ST
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92101-7609
Practice Address - Country:US
Practice Address - Phone:619-233-3432
Practice Address - Fax:619-233-7022
Is Sole Proprietor?:No
Enumeration Date:2007-03-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health