Provider Demographics
NPI:1467732842
Name:MOORHEAD, MACKLYN KELLEY (LCSW)
Entity Type:Individual
Prefix:MS
First Name:MACKLYN
Middle Name:KELLEY
Last Name:MOORHEAD
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:MCKELL
Other - Middle Name:
Other - Last Name:MOORHEAD
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:10263 GANDY BLVD N
Mailing Address - Street 2:APT 2114
Mailing Address - City:ST PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33702-2389
Mailing Address - Country:US
Mailing Address - Phone:727-482-1898
Mailing Address - Fax:
Practice Address - Street 1:10263 GANDY BLVD N APT 2114
Practice Address - Street 2:
Practice Address - City:SAINT PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33702-2329
Practice Address - Country:US
Practice Address - Phone:727-755-3021
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-08-17
Last Update Date:2015-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL86201041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical