Provider Demographics
NPI:1609388537
Name:MOORE, KYLIE K (MSW, LSW)
Entity Type:Individual
Prefix:
First Name:KYLIE
Middle Name:K
Last Name:MOORE
Suffix:
Gender:F
Credentials:MSW, LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2566 CASS RD
Mailing Address - Street 2:
Mailing Address - City:TOLEDO
Mailing Address - State:OH
Mailing Address - Zip Code:43614-4701
Mailing Address - Country:US
Mailing Address - Phone:419-304-8434
Mailing Address - Fax:
Practice Address - Street 1:4913 HARROUN RD STE 3
Practice Address - Street 2:
Practice Address - City:SYLVANIA
Practice Address - State:OH
Practice Address - Zip Code:43560-2102
Practice Address - Country:US
Practice Address - Phone:419-841-3003
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-11-01
Last Update Date:2017-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHS0800646104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker