Provider Demographics
NPI:1518488485
Name:WENDLAND-MOORE, KELSEY (LSCSW, LCSW)
Entity type:Individual
Prefix:
First Name:KELSEY
Middle Name:
Last Name:WENDLAND-MOORE
Suffix:
Gender:F
Credentials:LSCSW, LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4365 E PECOS RD STE 119
Mailing Address - Street 2:
Mailing Address - City:GILBERT
Mailing Address - State:AZ
Mailing Address - Zip Code:85295-8052
Mailing Address - Country:US
Mailing Address - Phone:480-680-0007
Mailing Address - Fax:
Practice Address - Street 1:4365 E PECOS RD STE 119
Practice Address - Street 2:
Practice Address - City:GILBERT
Practice Address - State:AZ
Practice Address - Zip Code:85295-8052
Practice Address - Country:US
Practice Address - Phone:480-680-0007
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-06-30
Last Update Date:2022-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS053151041C0700X
AZ199471041C0700X
KS10472104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS100098080COtherSED WAIVER
KS100098080AMedicaid