Healthcare Provider Details

I. General information

NPI: 1558987875
Provider Name (Legal Business Name): KELLY MOORE SCHIRR PHD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: KELLY ELIZABETH MOORE

II. Dates (important events)

Enumeration Date: 06/23/2020
Last Update Date: 06/23/2020
Certification Date: 06/23/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

166 DEROSIER DR
JOHNSON CITY TN
37614-5200
US

IV. Provider business mailing address

PO BOX 70416 ETSU DEPT OF PSYCHOLOGY
JOHNSON CITY TN
37614
US

V. Phone/Fax

Practice location:
  • Phone: 423-439-7777
  • Fax: 423-438-7780
Mailing address:
  • Phone: 423-439-4849
  • Fax: 423-439-7780

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number3594
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: