Provider Demographics
NPI:1275177255
Name:EBBERUP-KRUG, KELLIE ADRIENNE (LCSW)
Entity Type:Individual
Prefix:
First Name:KELLIE
Middle Name:ADRIENNE
Last Name:EBBERUP-KRUG
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:KELLIE
Other - Middle Name:ADRIENNE
Other - Last Name:KRUG
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:930 MORGAN DRIVE
Mailing Address - Street 2:
Mailing Address - City:WHITEMAN AFB
Mailing Address - State:MO
Mailing Address - Zip Code:65305-1180
Mailing Address - Country:US
Mailing Address - Phone:901-336-2626
Mailing Address - Fax:
Practice Address - Street 1:930 MORGAN DRIVE
Practice Address - Street 2:
Practice Address - City:WHITEMAN AFB
Practice Address - State:MO
Practice Address - Zip Code:65305-1180
Practice Address - Country:US
Practice Address - Phone:901-336-2626
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-11-01
Last Update Date:2019-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20190389351041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO490077188Medicaid