Provider Demographics
NPI:1134619018
Name:MOORE, KELLY MICHELLE (LCSW)
Entity type:Individual
Prefix:MS
First Name:KELLY
Middle Name:MICHELLE
Last Name:MOORE
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:301 FISHER STREET
Mailing Address - Street 2:KEESLER AFB MENTAL HEALTH CLINIC
Mailing Address - City:KEESLER AFB
Mailing Address - State:MS
Mailing Address - Zip Code:39534
Mailing Address - Country:US
Mailing Address - Phone:228-376-0385
Mailing Address - Fax:
Practice Address - Street 1:301 FISHER STREET
Practice Address - Street 2:
Practice Address - City:KEESLER AFB
Practice Address - State:MS
Practice Address - Zip Code:39534
Practice Address - Country:US
Practice Address - Phone:228-376-0385
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-16
Last Update Date:2023-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSM8385104100000X
MSC8385104100000X, 1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
MSM8385OtherMISSISSIPPI STATE BOARD OF SOCIAL WORK