Healthcare Provider Details

I. General information

NPI: 1518488485
Provider Name (Legal Business Name): KELSEY WENDLAND-MOORE LSCSW, LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/30/2017
Last Update Date: 07/20/2022
Certification Date: 07/20/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4365 E PECOS RD STE 119
GILBERT AZ
85295-8052
US

IV. Provider business mailing address

4365 E PECOS RD STE 119
GILBERT AZ
85295-8052
US

V. Phone/Fax

Practice location:
  • Phone: 480-680-0007
  • Fax:
Mailing address:
  • Phone: 480-680-0007
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number10472
License Number StateKS
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number05315
License Number StateKS
# 3
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number19947
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: