Provider Demographics
NPI:1902688757
Name:MOORE, KELLY
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
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 1:7 PERRINES BRIDGE RD
Mailing Address - Street 2:
Mailing Address - City:TILLSON
Mailing Address - State:NY
Mailing Address - Zip Code:12486-1704
Mailing Address - Country:US
Mailing Address - Phone:585-734-8096
Mailing Address - Fax:
Practice Address - Street 1:721 BROADWAY
Practice Address - Street 2:
Practice Address - City:KINGSTON
Practice Address - State:NY
Practice Address - Zip Code:12401-3449
Practice Address - Country:US
Practice Address - Phone:518-822-7702
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-10-17
Last Update Date:2023-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY109901104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker