Provider Demographics
NPI:1255521506
Name:DILLON-LEDUC, KELLI E (MSW)
Entity type:Individual
Prefix:
First Name:KELLI
Middle Name:E
Last Name:DILLON-LEDUC
Suffix:
Gender:
Credentials:MSW
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 1317
Mailing Address - Street 2:
Mailing Address - City:KIMBERLING CITY
Mailing Address - State:MO
Mailing Address - Zip Code:65686-1317
Mailing Address - Country:US
Mailing Address - Phone:417-859-7746
Mailing Address - Fax:417-538-4007
Practice Address - Street 1:205 W PARK AVE STE 103
Practice Address - Street 2:
Practice Address - City:CHAMPAIGN
Practice Address - State:IL
Practice Address - Zip Code:61820-7888
Practice Address - Country:US
Practice Address - Phone:217-850-1133
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-01
Last Update Date:2025-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO005176104100000X
IL1490286061041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO493959316Medicaid