Provider Demographics
NPI:1528466901
Name:MOORE, KELLY (PSYD)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:MOORE
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 644
Mailing Address - Street 2:
Mailing Address - City:RANCOCAS
Mailing Address - State:NJ
Mailing Address - Zip Code:08073-0644
Mailing Address - Country:US
Mailing Address - Phone:856-261-6590
Mailing Address - Fax:
Practice Address - Street 1:128 BORTONS LANDING RD
Practice Address - Street 2:SUITE 2
Practice Address - City:MOORESTOWN
Practice Address - State:NJ
Practice Address - Zip Code:08057-3011
Practice Address - Country:US
Practice Address - Phone:856-261-6590
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-12-16
Last Update Date:2014-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPS017654103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical