Provider Demographics
NPI:1639887524
Name:KELSO, MISTY
Entity Type:Individual
Prefix:
First Name:MISTY
Middle Name:
Last Name:KELSO
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 1:8702 W 49TH TER
Mailing Address - Street 2:
Mailing Address - City:MERRIAM
Mailing Address - State:KS
Mailing Address - Zip Code:66203-1710
Mailing Address - Country:US
Mailing Address - Phone:913-263-6006
Mailing Address - Fax:816-836-2923
Practice Address - Street 1:801 NE ANDERSON LN
Practice Address - Street 2:
Practice Address - City:LEES SUMMIT
Practice Address - State:MO
Practice Address - Zip Code:64064-1244
Practice Address - Country:US
Practice Address - Phone:913-263-6006
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-11-09
Last Update Date:2022-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
104100000X
KS10670104100000X
MO2022040360104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOK112105027OtherDRIVER'S LICENSE