Provider Demographics
NPI:1720053689
Name:KELLEY, SHARON L (LCSW)
Entity Type:Individual
Prefix:
First Name:SHARON
Middle Name:L
Last Name:KELLEY
Suffix:
Gender:F
Credentials:LCSW
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 1359
Mailing Address - Street 2:
Mailing Address - City:AVA
Mailing Address - State:MO
Mailing Address - Zip Code:65608-1359
Mailing Address - Country:US
Mailing Address - Phone:417-683-5739
Mailing Address - Fax:417-683-1602
Practice Address - Street 1:504 NW 10TH
Practice Address - Street 2:
Practice Address - City:AVA
Practice Address - State:MO
Practice Address - Zip Code:65608-1359
Practice Address - Country:US
Practice Address - Phone:417-683-5739
Practice Address - Fax:417-683-1602
Is Sole Proprietor?:No
Enumeration Date:2006-02-22
Last Update Date:2015-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL103981041C0700X
MO19991353841041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
P00122802OtherRAILROAD MEDICARE
MO499145522Medicaid
MO499145514Medicaid
FL004856200Medicaid
MO499145506Medicaid
189212OtherBLUE CROSS BLUE SHIELD
MO499145514Medicaid
FLGC705ZMedicare UPIN