1467732842 NPI number — MS. MACKLYN KELLEY MOORHEAD LCSW

Table of content: MS. MACKLYN KELLEY MOORHEAD LCSW (NPI 1467732842)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1467732842 NPI number — MS. MACKLYN KELLEY MOORHEAD LCSW

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MOORHEAD
Provider First Name:
MACKLYN
Provider Middle Name:
KELLEY
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
LCSW
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
MOORHEAD
Provider Other First Name:
MCKELL
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1467732842
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/15/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
10263 GANDY BLVD N
Provider Second Line Business Mailing Address:
APT 2114
Provider Business Mailing Address City Name:
ST PETERSBURG
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33702-2389
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
727-482-1898
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
10263 GANDY BLVD N APT 2114
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SAINT PETERSBURG
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33702-2329
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
727-755-3021
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
08/17/2011

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 1041C0700X , with the licence number:  8620 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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