Provider Demographics
NPI:1073827911
Name:KELLEDES, MICHAEL JON (LPC)
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:JON
Last Name:KELLEDES
Suffix:
Gender:M
Credentials:LPC
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 C
Mailing Address - Street 2:
Mailing Address - City:WARRENSBURG
Mailing Address - State:MO
Mailing Address - Zip Code:64093-3107
Mailing Address - Country:US
Mailing Address - Phone:660-429-6678
Mailing Address - Fax:660-429-6672
Practice Address - Street 1:407 E RUSSELL AVE
Practice Address - Street 2:STE A5
Practice Address - City:WARRENSBURG
Practice Address - State:MO
Practice Address - Zip Code:64093-3107
Practice Address - Country:US
Practice Address - Phone:660-429-6678
Practice Address - Fax:660-429-6672
Is Sole Proprietor?:Yes
Enumeration Date:2010-08-03
Last Update Date:2010-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2008004415101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor