Provider Demographics
NPI:1447640958
Name:KELLY, MOISE
Entity type:Individual
Prefix:MR
First Name:MOISE
Middle Name:
Last Name:KELLY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:455 S MESA DR UNIT 142
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85210-2711
Mailing Address - Country:US
Mailing Address - Phone:480-616-3323
Mailing Address - Fax:
Practice Address - Street 1:455 S MESA DR UNIT 142
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85210-2711
Practice Address - Country:US
Practice Address - Phone:480-277-0313
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-02-04
Last Update Date:2019-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ957399101Y00000X, 104100000X, 171M00000X, 174H00000X, 172V00000X, 103TC2200X, 103TH0100X, 171M00000X, 172V00000X, 174H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
No174H00000XOther Service ProvidersHealth Educator
Yes172V00000XOther Service ProvidersCommunity Health Worker
No103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent
No103TH0100XBehavioral Health & Social Service ProvidersPsychologistHealth Service
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ957399Medicaid