Provider Demographics
NPI:1275820540
Name:LOUGHMILLER, KELLIE ANN (LMSW)
Entity Type:Individual
Prefix:MISS
First Name:KELLIE
Middle Name:ANN
Last Name:LOUGHMILLER
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:111 N 15TH ST
Mailing Address - Street 2:APT. 912
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63103-1988
Mailing Address - Country:US
Mailing Address - Phone:573-579-7176
Mailing Address - Fax:
Practice Address - Street 1:111 N 15TH ST
Practice Address - Street 2:APT. 912
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63103-1988
Practice Address - Country:US
Practice Address - Phone:573-579-7176
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-07-06
Last Update Date:2017-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171M00000X
MO20160183131041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO2016018313OtherLICENSE