Provider Demographics
NPI:1689402455
Name:MOORE, KELLY J (LSCSW, LAC)
Entity type:Individual
Prefix:MRS
First Name:KELLY
Middle Name:J
Last Name:MOORE
Suffix:
Gender:F
Credentials:LSCSW, LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1126 S. CLIFTON AVE.
Mailing Address - Street 2:
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67218-2913
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1126 S CLIFTON AVE
Practice Address - Street 2:
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67218-2913
Practice Address - Country:US
Practice Address - Phone:316-208-5220
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-07-23
Last Update Date:2024-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS064961041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical