Provider Demographics
NPI:1538107370
Name:MIESSE, KELLI RAE (MA, LPC)
Entity Type:Individual
Prefix:
First Name:KELLI
Middle Name:RAE
Last Name:MIESSE
Suffix:
Gender:F
Credentials:MA, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5520 LANE AVE
Mailing Address - Street 2:
Mailing Address - City:RAYTOWN
Mailing Address - State:MO
Mailing Address - Zip Code:64133-3254
Mailing Address - Country:US
Mailing Address - Phone:816-516-6593
Mailing Address - Fax:
Practice Address - Street 1:9500 E 63RD ST STE 108
Practice Address - Street 2:
Practice Address - City:RAYTOWN
Practice Address - State:MO
Practice Address - Zip Code:64133-4951
Practice Address - Country:US
Practice Address - Phone:816-960-7111
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-03
Last Update Date:2022-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2003030550101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO499095701Medicaid