Provider Demographics
NPI:1376740829
Name:MEHAN, KELLY KUBALA (LCSW)
Entity Type:Individual
Prefix:MRS
First Name:KELLY
Middle Name:KUBALA
Last Name:MEHAN
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5854 WALSH ST
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63109-3120
Mailing Address - Country:US
Mailing Address - Phone:314-440-5800
Mailing Address - Fax:
Practice Address - Street 1:408 JEFFERSON STREET
Practice Address - Street 2:
Practice Address - City:ST. CHARLES
Practice Address - State:MO
Practice Address - Zip Code:63301
Practice Address - Country:US
Practice Address - Phone:314-440-5800
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-28
Last Update Date:2013-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20060183061041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical