Provider Demographics
NPI:1376722348
Name:MOORE, KENNETH JERALD (PHD LCSW)
Entity Type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:JERALD
Last Name:MOORE
Suffix:
Gender:M
Credentials:PHD LCSW
Other - Prefix:DR
Other - First Name:KEN
Other - Middle Name:J
Other - Last Name:MOORE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PHD, LCSW
Mailing Address - Street 1:6906 S UTICA PL
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74136-5158
Mailing Address - Country:US
Mailing Address - Phone:918-794-4596
Mailing Address - Fax:
Practice Address - Street 1:6906 S UTICA PL
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74136-5158
Practice Address - Country:US
Practice Address - Phone:918-794-4596
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-26
Last Update Date:2009-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK21651041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical