Provider Demographics
NPI:1558401836
Name:MOORE, KELLY N (MSSW, LCSW)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:N
Last Name:MOORE
Suffix:
Gender:F
Credentials:MSSW, LCSW
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:N
Other - Last Name:PORTH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MSSW, CSW
Mailing Address - Street 1:1306 VERSAILLES RD STE 120
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40504-1795
Mailing Address - Country:US
Mailing Address - Phone:859-259-2635
Mailing Address - Fax:859-254-7874
Practice Address - Street 1:1306 VERSAILLES RD STE 120
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40504-1795
Practice Address - Country:US
Practice Address - Phone:859-259-2635
Practice Address - Fax:859-254-7874
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-07
Last Update Date:2015-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY35301041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100290050Medicaid
KYK179870Medicare PIN