Provider Demographics
NPI:1366880809
Name:MOORE, KELLY R (LSCSW)
Entity type:Individual
Prefix:MS
First Name:KELLY
Middle Name:R
Last Name:MOORE
Suffix:
Gender:F
Credentials:LSCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13217 W 107TH TER
Mailing Address - Street 2:
Mailing Address - City:LENEXA
Mailing Address - State:KS
Mailing Address - Zip Code:66210-3726
Mailing Address - Country:US
Mailing Address - Phone:913-963-7751
Mailing Address - Fax:
Practice Address - Street 1:11261 STRANG LINE RD
Practice Address - Street 2:
Practice Address - City:LENEXA
Practice Address - State:KS
Practice Address - Zip Code:66215-4040
Practice Address - Country:US
Practice Address - Phone:913-353-6021
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-06-06
Last Update Date:2023-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS4470104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker