Provider Demographics
NPI:1326177247
Name:MURDOCK, KELLY (PSYCHOLOGIST)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:MURDOCK
Suffix:
Gender:F
Credentials:PSYCHOLOGIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 3311
Mailing Address - Street 2:
Mailing Address - City:CAMP VERDE
Mailing Address - State:AZ
Mailing Address - Zip Code:86322
Mailing Address - Country:US
Mailing Address - Phone:928-567-7014
Mailing Address - Fax:928-567-7014
Practice Address - Street 1:8766 EAST HWY 69
Practice Address - Street 2:HUMBOLDT UNIFIED SCHOOL DISTRICT 22
Practice Address - City:PRESCOTT VALLEY
Practice Address - State:AZ
Practice Address - Zip Code:86314
Practice Address - Country:US
Practice Address - Phone:928-759-4028
Practice Address - Fax:928-759-4030
Is Sole Proprietor?:No
Enumeration Date:2007-03-05
Last Update Date:2007-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ639750Medicaid