Provider Demographics
NPI:1417152414
Name:RHOADES, KELLY DAN (PLPC, MA)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:DAN
Last Name:RHOADES
Suffix:
Gender:M
Credentials:PLPC, MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1321 NATHANIEL DR
Mailing Address - Street 2:
Mailing Address - City:LEBANON
Mailing Address - State:MO
Mailing Address - Zip Code:65536-8904
Mailing Address - Country:US
Mailing Address - Phone:417-322-2285
Mailing Address - Fax:
Practice Address - Street 1:235 W COMMERCIAL ST
Practice Address - Street 2:
Practice Address - City:LEBANON
Practice Address - State:MO
Practice Address - Zip Code:65536-3145
Practice Address - Country:US
Practice Address - Phone:417-532-6359
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2007015291101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1437228905Medicaid