Provider Demographics
NPI:1134207269
Name:IRVINE, KELLY L (PSYD)
Entity type:Individual
Prefix:DR
First Name:KELLY
Middle Name:L
Last Name:IRVINE
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:DR
Other - First Name:KELLY
Other - Middle Name:L
Other - Last Name:MOYNIHAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PSYD
Mailing Address - Street 1:1800 COMMUNITY
Mailing Address - Street 2:
Mailing Address - City:CLINTON
Mailing Address - State:MO
Mailing Address - Zip Code:64735-8804
Mailing Address - Country:US
Mailing Address - Phone:660-890-8156
Mailing Address - Fax:
Practice Address - Street 1:1000 W NIFONG BLVD BLDG 6
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:MO
Practice Address - Zip Code:65203-5615
Practice Address - Country:US
Practice Address - Phone:888-403-1071
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-02
Last Update Date:2019-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2018042229103TB0200X
AZ3482103TC0700X, 103TF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Yes103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & Behavioral
No103TF0000XBehavioral Health & Social Service ProvidersPsychologistFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
50583OtherNRHSP IN PSYCH
AZNATIONAL REGISTER #Other50583
AZAPA MEMBERSHIP #Other69103091
AZAZ0616050OtherBC/BS
AZ116730OtherBHN
AZ5457314OtherFIRST HEALTH/CNN
IA415OtherIA HSP #
LA141592Medicaid
AZ803925Medicaid
AZ2128566OtherCIGNA
AZ228289OtherONE HEALTH & GWL
AZ291968OtherMHN
4142OtherCPQ
AZ86-1043861OtherMAGELAN, BIODYNE, AETNA
AZAPA MEMBERSHIP #Other69103091
AZ2128566OtherCIGNA
50583OtherNRHSP IN PSYCH
AZ803925Medicaid
AZ116730OtherBHN