Provider Demographics
NPI:1982855649
Name:KIRBY, KELLY LARAE (MSW, LMSW)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:LARAE
Last Name:KIRBY
Suffix:
Gender:F
Credentials:MSW, LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 593
Mailing Address - Street 2:
Mailing Address - City:PEA RIDGE
Mailing Address - State:AR
Mailing Address - Zip Code:72751-0593
Mailing Address - Country:US
Mailing Address - Phone:479-228-0817
Mailing Address - Fax:
Practice Address - Street 1:1100 N COLLEGE AVE
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:AR
Practice Address - Zip Code:72703-1944
Practice Address - Country:US
Practice Address - Phone:479-587-5919
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-09-30
Last Update Date:2008-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR999999104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker