Provider Demographics
NPI:1619937414
Name:KELLENBERGER, JUDITH A
Entity Type:Individual
Prefix:
First Name:JUDITH
Middle Name:A
Last Name:KELLENBERGER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:JUDITH
Other - Middle Name:A
Other - Last Name:GARRITY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MS
Mailing Address - Street 1:3555 ALPACA RD
Mailing Address - Street 2:
Mailing Address - City:JOPLIN
Mailing Address - State:MO
Mailing Address - Zip Code:64804-8735
Mailing Address - Country:US
Mailing Address - Phone:417-781-9160
Mailing Address - Fax:
Practice Address - Street 1:1230 N DUQUESNE RD
Practice Address - Street 2:
Practice Address - City:JOPLIN
Practice Address - State:MO
Practice Address - Zip Code:64801-1509
Practice Address - Country:US
Practice Address - Phone:417-782-1443
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-24
Last Update Date:2014-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO01618103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO496912734Medicaid