Provider Demographics
NPI:1619918869
Name:MOORE, KRISTY L (MSW)
Entity Type:Individual
Prefix:MS
First Name:KRISTY
Middle Name:L
Last Name:MOORE
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2633 N PETERSON DR
Mailing Address - Street 2:
Mailing Address - City:SANFORD
Mailing Address - State:MI
Mailing Address - Zip Code:48657-9487
Mailing Address - Country:US
Mailing Address - Phone:989-687-7859
Mailing Address - Fax:
Practice Address - Street 1:201 MULHOLLAND ST
Practice Address - Street 2:
Practice Address - City:BAY CITY
Practice Address - State:MI
Practice Address - Zip Code:48708-7693
Practice Address - Country:US
Practice Address - Phone:989-895-2205
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010847701041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIN42500011Medicare ID - Type Unspecified