Provider Demographics
NPI:1619674371
Name:RICHMOND-MOORE, KELLY (LCSW, PPSC)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:RICHMOND-MOORE
Suffix:
Gender:F
Credentials:LCSW, PPSC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 TIGER WAY
Mailing Address - Street 2:
Mailing Address - City:ROSEVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95678-1706
Mailing Address - Country:US
Mailing Address - Phone:916-782-3753
Mailing Address - Fax:
Practice Address - Street 1:1 TIGER WAY
Practice Address - Street 2:
Practice Address - City:ROSEVILLE
Practice Address - State:CA
Practice Address - Zip Code:95678-1706
Practice Address - Country:US
Practice Address - Phone:916-782-3753
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-02-13
Last Update Date:2023-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA277791041S0200X, 1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No1041S0200XBehavioral Health & Social Service ProvidersSocial WorkerSchool