Provider Demographics
NPI:1003846304
Name:MOORE, KELLY WATKINS (LCSW)
Entity type:Individual
Prefix:MS
First Name:KELLY
Middle Name:WATKINS
Last Name:MOORE
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:MS
Other - First Name:KELLY
Other - Middle Name:D
Other - Last Name:WATKINS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LCSW
Mailing Address - Street 1:463 WESTFIELD BLVD
Mailing Address - Street 2:APT 913
Mailing Address - City:TEMPLE
Mailing Address - State:TX
Mailing Address - Zip Code:76502-5318
Mailing Address - Country:US
Mailing Address - Phone:254-743-2904
Mailing Address - Fax:
Practice Address - Street 1:1901 VETERANS MEMORIAL DR
Practice Address - Street 2:
Practice Address - City:TEMPLE
Practice Address - State:TX
Practice Address - Zip Code:76504-7451
Practice Address - Country:US
Practice Address - Phone:254-743-2904
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-03
Last Update Date:2010-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX35991104100000X, 1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical