Provider Demographics
NPI:1396080644
Name:MOSLEY, KELLI L
Entity type:Individual
Prefix:
First Name:KELLI
Middle Name:L
Last Name:MOSLEY
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:PO BOX 751953
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89136-1953
Mailing Address - Country:US
Mailing Address - Phone:916-708-2308
Mailing Address - Fax:
Practice Address - Street 1:6171 W CHARLESTON BLVD
Practice Address - Street 2:BLDG 7
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89146-1126
Practice Address - Country:US
Practice Address - Phone:702-486-0003
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-11-27
Last Update Date:2016-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
225400000X
NVMI0629106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner