Provider Demographics
NPI:1386175420
Name:MORAN, KELLY
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:MORAN
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 1:3817 WILLOWICK PARK DR
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:28409-3700
Mailing Address - Country:US
Mailing Address - Phone:440-590-0698
Mailing Address - Fax:
Practice Address - Street 1:5710 OLEANDER DR
Practice Address - Street 2:SUITE 112
Practice Address - City:WILMINGTON
Practice Address - State:NC
Practice Address - Zip Code:28403
Practice Address - Country:US
Practice Address - Phone:910-769-1785
Practice Address - Fax:910-769-3965
Is Sole Proprietor?:No
Enumeration Date:2017-03-21
Last Update Date:2018-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC12371101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health