Provider Demographics
NPI:1093879835
Name:STADDIE, KELLY RAE (LCSW)
Entity Type:Individual
Prefix:MRS
First Name:KELLY
Middle Name:RAE
Last Name:STADDIE
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:MISS
Other - First Name:KELLY
Other - Middle Name:RAE
Other - Last Name:SPORTSMAN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:24 LAKESIDE PL
Mailing Address - Street 2:
Mailing Address - City:MEXICO
Mailing Address - State:MO
Mailing Address - Zip Code:65265-2227
Mailing Address - Country:US
Mailing Address - Phone:573-582-7866
Mailing Address - Fax:
Practice Address - Street 1:734 W MONROE ST
Practice Address - Street 2:
Practice Address - City:MEXICO
Practice Address - State:MO
Practice Address - Zip Code:65265-1970
Practice Address - Country:US
Practice Address - Phone:573-642-5345
Practice Address - Fax:573-642-5162
Is Sole Proprietor?:No
Enumeration Date:2006-12-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20050083561041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical