Provider Demographics
NPI:1861844698
Name:LARKIN, KELLY
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:LARKIN
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 1:811 CORVALLIS CT
Mailing Address - Street 2:
Mailing Address - City:ELLISVILLE
Mailing Address - State:MO
Mailing Address - Zip Code:63021-4767
Mailing Address - Country:US
Mailing Address - Phone:314-941-0875
Mailing Address - Fax:
Practice Address - Street 1:811 CORVALLIS CT.
Practice Address - Street 2:
Practice Address - City:ELLISVILLE
Practice Address - State:MO
Practice Address - Zip Code:63021-4767
Practice Address - Country:US
Practice Address - Phone:314-941-0875
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-07-05
Last Update Date:2016-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2016019115101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor