Provider Demographics
NPI:1245519396
Name:MOORE, KATHLEEN MARY (LISW)
Entity type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:MARY
Last Name:MOORE
Suffix:
Gender:F
Credentials:LISW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:315 ARNO ST SE
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87102-3514
Mailing Address - Country:US
Mailing Address - Phone:505-710-2209
Mailing Address - Fax:
Practice Address - Street 1:1218 GRIEGOS RD NW
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87107-3752
Practice Address - Country:US
Practice Address - Phone:505-342-5450
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-08-08
Last Update Date:2011-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMI-055671041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical