Provider Demographics
NPI:1770195380
Name:MOORE, KELLI (LPCC)
Entity Type:Individual
Prefix:
First Name:KELLI
Middle Name:
Last Name:MOORE
Suffix:
Gender:F
Credentials:LPCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1622 7TH ST
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NM
Mailing Address - Zip Code:87701-4920
Mailing Address - Country:US
Mailing Address - Phone:505-310-7280
Mailing Address - Fax:
Practice Address - Street 1:1622 7TH ST
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NM
Practice Address - Zip Code:87701-4920
Practice Address - Country:US
Practice Address - Phone:505-310-7280
Practice Address - Fax:505-425-5408
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-17
Last Update Date:2023-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMCSA0211311104100000X
NMCTB-2023-0541101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No104100000XBehavioral Health & Social Service ProvidersSocial Worker