Provider Demographics
NPI:1770996456
Name:PROFFITT, KELLI
Entity type:Individual
Prefix:
First Name:KELLI
Middle Name:
Last Name:PROFFITT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:KELLI
Other - Middle Name:
Other - Last Name:BERNDSEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4101 S 4TH ST
Mailing Address - Street 2:
Mailing Address - City:LEAVENWORTH
Mailing Address - State:KS
Mailing Address - Zip Code:66048-5014
Mailing Address - Country:US
Mailing Address - Phone:785-640-8176
Mailing Address - Fax:913-758-6840
Practice Address - Street 1:4101 S 4TH ST
Practice Address - Street 2:
Practice Address - City:LEAVENWORTH
Practice Address - State:KS
Practice Address - Zip Code:66048-5014
Practice Address - Country:US
Practice Address - Phone:785-640-8176
Practice Address - Fax:139-758-6840
Is Sole Proprietor?:No
Enumeration Date:2014-06-10
Last Update Date:2024-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS48581041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical