Provider Demographics
NPI:1528601689
Name:KELLEY, MORGAN
Entity Type:Individual
Prefix:
First Name:MORGAN
Middle Name:
Last Name:KELLEY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2620 FORUM BLVD STE E
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:MO
Mailing Address - Zip Code:65203-5454
Mailing Address - Country:US
Mailing Address - Phone:573-514-8735
Mailing Address - Fax:
Practice Address - Street 1:2620 FORUM BLVD STE E
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:MO
Practice Address - Zip Code:65203-5454
Practice Address - Country:US
Practice Address - Phone:573-514-8735
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-10-22
Last Update Date:2022-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106S00000X
MORBT-22-238968106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician