Provider Demographics
NPI:1578666723
Name:WILBANKS, KELLEY GAYE (LPC)
Entity Type:Individual
Prefix:MS
First Name:KELLEY
Middle Name:GAYE
Last Name:WILBANKS
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3411 DIVISION DR
Mailing Address - Street 2:
Mailing Address - City:WEST PLAINS
Mailing Address - State:MO
Mailing Address - Zip Code:65775-5789
Mailing Address - Country:US
Mailing Address - Phone:417-257-9152
Mailing Address - Fax:417-257-9162
Practice Address - Street 1:3411 DIVISION DR
Practice Address - Street 2:
Practice Address - City:WEST PLAINS
Practice Address - State:MO
Practice Address - Zip Code:65775-5789
Practice Address - Country:US
Practice Address - Phone:417-257-9152
Practice Address - Fax:417-257-9162
Is Sole Proprietor?:No
Enumeration Date:2006-09-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO494720303101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO494720303Medicaid
MO151551OtherBLUE CROSS BLUE SHIELD
MO431116734OtherNEW DIRECTIONS
MO431116734OtherEAP INTERFACE
MO11545393OtherCAQH
MO713333OtherHEALTHLINK PPO