Provider Demographics
NPI:1992215271
Name:ADKINS, KELLY D (LCSW)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:D
Last Name:ADKINS
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:D
Other - Last Name:CHANCE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LCSW
Mailing Address - Street 1:724 N 22ND ST
Mailing Address - Street 2:
Mailing Address - City:SAINT JOSEPH
Mailing Address - State:MO
Mailing Address - Zip Code:64506-2604
Mailing Address - Country:US
Mailing Address - Phone:816-261-4939
Mailing Address - Fax:
Practice Address - Street 1:5001 LAKE AVE
Practice Address - Street 2:
Practice Address - City:SAINT JOSEPH
Practice Address - State:MO
Practice Address - Zip Code:64504-1170
Practice Address - Country:US
Practice Address - Phone:816-238-7788
Practice Address - Fax:816-238-9298
Is Sole Proprietor?:No
Enumeration Date:2017-10-02
Last Update Date:2021-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2017017986104100000X
MO20200006641041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO490066457Medicaid