Provider Demographics
NPI:1053091454
Name:MOORE, KALLIE JO
Entity type:Individual
Prefix:
First Name:KALLIE
Middle Name:JO
Last Name:MOORE
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 1:1418 GARVIN RDG
Mailing Address - Street 2:
Mailing Address - City:OLIVE HILL
Mailing Address - State:KY
Mailing Address - Zip Code:41164-8937
Mailing Address - Country:US
Mailing Address - Phone:606-923-9683
Mailing Address - Fax:
Practice Address - Street 1:104 MARKET PATH
Practice Address - Street 2:
Practice Address - City:GEORGETOWN
Practice Address - State:KY
Practice Address - Zip Code:40324-1579
Practice Address - Country:US
Practice Address - Phone:502-632-6241
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-07-20
Last Update Date:2023-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician