Provider Demographics
NPI:1932487303
Name:MOORE, KELLIE (LPC)
Entity Type:Individual
Prefix:
First Name:KELLIE
Middle Name:
Last Name:MOORE
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3670 HIGHLANDS PKWY SE
Mailing Address - Street 2:BUILDING 6
Mailing Address - City:SMYRNA
Mailing Address - State:GA
Mailing Address - Zip Code:30082-5184
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3670 HIGHLANDS PKWY SE
Practice Address - Street 2:BUILDING 6
Practice Address - City:SMYRNA
Practice Address - State:GA
Practice Address - Zip Code:30082-5184
Practice Address - Country:US
Practice Address - Phone:404-856-7600
Practice Address - Fax:404-856-7601
Is Sole Proprietor?:Yes
Enumeration Date:2011-08-02
Last Update Date:2011-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALPC006309101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional