Provider Demographics
NPI:1801207089
Name:MOORE, KELLI LYN
Entity Type:Individual
Prefix:MRS
First Name:KELLI
Middle Name:LYN
Last Name:MOORE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1032 S DOUGLAS BLVD
Mailing Address - Street 2:
Mailing Address - City:MIDWEST CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73130-5209
Mailing Address - Country:US
Mailing Address - Phone:405-455-7740
Mailing Address - Fax:405-455-7745
Practice Address - Street 1:1032 S DOUGLAS BLVD
Practice Address - Street 2:
Practice Address - City:MIDWEST CITY
Practice Address - State:OK
Practice Address - Zip Code:73130-5209
Practice Address - Country:US
Practice Address - Phone:405-455-7740
Practice Address - Fax:405-455-7745
Is Sole Proprietor?:Yes
Enumeration Date:2014-05-09
Last Update Date:2014-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst