Provider Demographics
NPI:1144418146
Name:JOSEPHINE KELLY
Entity Type:Organization
Organization Name:JOSEPHINE KELLY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PSYCHOLOGIST
Authorized Official - Prefix:
Authorized Official - First Name:JOSEPHINE
Authorized Official - Middle Name:M
Authorized Official - Last Name:KELLY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:314-503-5657
Mailing Address - Street 1:115 PIPER HILL DR
Mailing Address - Street 2:
Mailing Address - City:SAINT PETERS
Mailing Address - State:MO
Mailing Address - Zip Code:63376-2589
Mailing Address - Country:US
Mailing Address - Phone:314-503-5657
Mailing Address - Fax:
Practice Address - Street 1:115 PIPER HILL DR
Practice Address - Street 2:
Practice Address - City:ST. PETERS
Practice Address - State:MO
Practice Address - Zip Code:63376
Practice Address - Country:US
Practice Address - Phone:314-503-5657
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-04
Last Update Date:2007-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO01352251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health