Provider Demographics
NPI:1861778029
Name:ALLEN, KELLI (MED, LPC)
Entity type:Individual
Prefix:MRS
First Name:KELLI
Middle Name:
Last Name:ALLEN
Suffix:
Gender:F
Credentials:MED, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6106 KENSINGTON COURT
Mailing Address - Street 2:
Mailing Address - City:IMPERIAL
Mailing Address - State:MO
Mailing Address - Zip Code:63052
Mailing Address - Country:US
Mailing Address - Phone:314-602-9207
Mailing Address - Fax:636-223-0905
Practice Address - Street 1:6106 KENSINGTON COURT
Practice Address - Street 2:
Practice Address - City:IMPERIAL
Practice Address - State:MO
Practice Address - Zip Code:63052
Practice Address - Country:US
Practice Address - Phone:314-602-9207
Practice Address - Fax:636-223-0905
Is Sole Proprietor?:Yes
Enumeration Date:2011-11-01
Last Update Date:2011-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2010009618101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional