Provider Demographics
NPI:1619080272
Name:MOORE, KELLY KING (MS, OTR/L)
Entity Type:Individual
Prefix:MRS
First Name:KELLY
Middle Name:KING
Last Name:MOORE
Suffix:
Gender:F
Credentials:MS, OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:330 WALLER AVE STE 275
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40504-2930
Mailing Address - Country:US
Mailing Address - Phone:859-447-8600
Mailing Address - Fax:859-447-8599
Practice Address - Street 1:330 WALLER AVE STE 275
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40504-2930
Practice Address - Country:US
Practice Address - Phone:859-447-8600
Practice Address - Fax:859-447-8599
Is Sole Proprietor?:No
Enumeration Date:2006-08-17
Last Update Date:2021-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYR3638225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100401980Medicaid