Provider Demographics
NPI:1992463095
Name:MOORE, KEELY V (MS)
Entity type:Individual
Prefix:MS
First Name:KEELY
Middle Name:V
Last Name:MOORE
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:21 AUDREY AVE
Mailing Address - Street 2:
Mailing Address - City:TYNGSBORO
Mailing Address - State:MA
Mailing Address - Zip Code:01879-1332
Mailing Address - Country:US
Mailing Address - Phone:978-995-2965
Mailing Address - Fax:
Practice Address - Street 1:278 MILL RD
Practice Address - Street 2:
Practice Address - City:CHELMSFORD
Practice Address - State:MA
Practice Address - Zip Code:01824-4106
Practice Address - Country:US
Practice Address - Phone:978-995-2965
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-12-06
Last Update Date:2024-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MABACB538069103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst