Provider Demographics
NPI:1861757148
Name:O'BERRY, KELLY RENNICK (LISW)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:RENNICK
Last Name:O'BERRY
Suffix:
Gender:F
Credentials:LISW
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:ANN
Other - Last Name:RENNICK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:7755 OFFICE PLAZA DR N
Mailing Address - Street 2:SUITE 105
Mailing Address - City:WEST DES MOINES
Mailing Address - State:IA
Mailing Address - Zip Code:50266-2339
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:7755 OFFICE PLAZA DR N
Practice Address - Street 2:SUITE 105
Practice Address - City:WEST DES MOINES
Practice Address - State:IA
Practice Address - Zip Code:50266-2339
Practice Address - Country:US
Practice Address - Phone:515-201-0439
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-11
Last Update Date:2017-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA06475104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA1861757148Medicaid
IA1861757148Medicaid