Provider Demographics
NPI:1629132519
Name:KELLY, JOSEPHINE MAY (MA)
Entity Type:Individual
Prefix:
First Name:JOSEPHINE
Middle Name:MAY
Last Name:KELLY
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6 JUNGERMANN CIR
Mailing Address - Street 2:SUITE 203
Mailing Address - City:SAINT PETERS
Mailing Address - State:MO
Mailing Address - Zip Code:63376-1621
Mailing Address - Country:US
Mailing Address - Phone:636-939-4247
Mailing Address - Fax:
Practice Address - Street 1:6 JUNGERMANN CIR
Practice Address - Street 2:SUITE 203
Practice Address - City:SAINT PETERS
Practice Address - State:MO
Practice Address - Zip Code:63376-1621
Practice Address - Country:US
Practice Address - Phone:636-939-4247
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOPYO1352103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO102105OtherVALUE OPTIONS
MO113437OtherBLUE CROSS BLUE SHIELD
MOP00279517Medicare ID - Type UnspecifiedMEDICARE RAILROAD