Provider Demographics
NPI:1205026531
Name:MOORE, KELLEY RENE (MHPP)
Entity Type:Individual
Prefix:
First Name:KELLEY
Middle Name:RENE
Last Name:MOORE
Suffix:
Gender:F
Credentials:MHPP
Other - Prefix:
Other - First Name:MARIE
Other - Middle Name:
Other - Last Name:SHELTON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:ACSW, LCSW
Mailing Address - Street 1:4425 JEFFERSON AVE
Mailing Address - Street 2:SUITE 106
Mailing Address - City:TEXARKANA
Mailing Address - State:AR
Mailing Address - Zip Code:71854-1535
Mailing Address - Country:US
Mailing Address - Phone:870-216-1700
Mailing Address - Fax:
Practice Address - Street 1:4425 JEFFERSON AVE
Practice Address - Street 2:SUITE 106
Practice Address - City:TEXARKANA
Practice Address - State:AR
Practice Address - Zip Code:71854-1535
Practice Address - Country:US
Practice Address - Phone:870-216-1700
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-01
Last Update Date:2007-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator