Provider Demographics
NPI:1659471597
Name:MOUNT, KELLEY ANN (PHD LPC)
Entity Type:Individual
Prefix:
First Name:KELLEY
Middle Name:ANN
Last Name:MOUNT
Suffix:
Gender:F
Credentials:PHD LPC
Other - Prefix:
Other - First Name:KELLEY
Other - Middle Name:ANN
Other - Last Name:GRASLE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PHD LPC
Mailing Address - Street 1:1600 HERITAGE LANDING
Mailing Address - Street 2:SUITE 116
Mailing Address - City:ST. PETERS
Mailing Address - State:MO
Mailing Address - Zip Code:63303
Mailing Address - Country:US
Mailing Address - Phone:636-345-1400
Mailing Address - Fax:636-441-3262
Practice Address - Street 1:1600 HERITAGE LANDING
Practice Address - Street 2:SUITE 116
Practice Address - City:ST PETERS
Practice Address - State:MO
Practice Address - Zip Code:63303
Practice Address - Country:US
Practice Address - Phone:636-345-1400
Practice Address - Fax:636-441-3262
Is Sole Proprietor?:No
Enumeration Date:2006-09-22
Last Update Date:2010-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO002586101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO493840425Medicaid