Provider Demographics
NPI:1730315755
Name:MOUW, KELLY MARIE
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:MARIE
Last Name:MOUW
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 1:1005 PILOT AVE
Mailing Address - Street 2:
Mailing Address - City:CHEROKEE
Mailing Address - State:IA
Mailing Address - Zip Code:51012
Mailing Address - Country:US
Mailing Address - Phone:712-899-4580
Mailing Address - Fax:
Practice Address - Street 1:180 10TH ST SE
Practice Address - Street 2:SUITE 201
Practice Address - City:LE MARS
Practice Address - State:IA
Practice Address - Zip Code:51031-2546
Practice Address - Country:US
Practice Address - Phone:712-546-4624
Practice Address - Fax:712-546-9395
Is Sole Proprietor?:No
Enumeration Date:2009-06-04
Last Update Date:2011-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA000344106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist