Provider Demographics
NPI:1669718144
Name:KELLY-MOSS, KERILYNN
Entity type:Individual
Prefix:
First Name:KERILYNN
Middle Name:
Last Name:KELLY-MOSS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:709 MACON DR
Mailing Address - Street 2:
Mailing Address - City:TITUSVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32780-4919
Mailing Address - Country:US
Mailing Address - Phone:321-264-1515
Mailing Address - Fax:
Practice Address - Street 1:3270 SUNTREE BLVD STE 100
Practice Address - Street 2:
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32940-7532
Practice Address - Country:US
Practice Address - Phone:321-610-7949
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-01-02
Last Update Date:2013-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health