Provider Demographics
NPI:1174651855
Name:WILLIAMS ROACH, KEALEY ANNE (LPC)
Entity Type:Individual
Prefix:
First Name:KEALEY
Middle Name:ANNE
Last Name:WILLIAMS ROACH
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7306 NEWTON DR
Mailing Address - Street 2:
Mailing Address - City:OVERLAND PARK
Mailing Address - State:KS
Mailing Address - Zip Code:66204-1848
Mailing Address - Country:US
Mailing Address - Phone:816-686-9499
Mailing Address - Fax:816-836-2923
Practice Address - Street 1:18600 E 37TH TER S
Practice Address - Street 2:
Practice Address - City:INDEPENDENCE
Practice Address - State:MO
Practice Address - Zip Code:64057-1707
Practice Address - Country:US
Practice Address - Phone:816-350-0215
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-02
Last Update Date:2022-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2001018056101YM0800X, 101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO495378317Medicaid