Healthcare Provider Details

I. General information

NPI: 1215115001
Provider Name (Legal Business Name): KAYLAN BETH MOORE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/05/2008
Last Update Date: 09/13/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

99 PASSMORE ROAD
WILMINGTON DE
19803
US

IV. Provider business mailing address

99 PASSMORE ROAD
WILMINGTON DE
19803
US

V. Phone/Fax

Practice location:
  • Phone: 302-478-9411
  • Fax: 302-479-9883
Mailing address:
  • Phone: 302-478-9411
  • Fax: 302-479-9883

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberQ1-0001163
License Number StateDE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: