1659471597 NPI number — KELLEY ANN MOUNT PHD LPC

Table of content: KELLEY ANN MOUNT PHD LPC (NPI 1659471597)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1659471597 NPI number — KELLEY ANN MOUNT PHD LPC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MOUNT
Provider First Name:
KELLEY
Provider Middle Name:
ANN
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PHD LPC
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
GRASLE
Provider Other First Name:
KELLEY
Provider Other Middle Name:
ANN
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
PHD LPC
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1659471597
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/28/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1600 HERITAGE LANDING
Provider Second Line Business Mailing Address:
SUITE 116
Provider Business Mailing Address City Name:
ST. PETERS
Provider Business Mailing Address State Name:
MO
Provider Business Mailing Address Postal Code:
63303
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
636-345-1400
Provider Business Mailing Address Fax Number:
636-441-3262

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1600 HERITAGE LANDING
Provider Second Line Business Practice Location Address:
SUITE 116
Provider Business Practice Location Address City Name:
ST PETERS
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
63303
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
636-345-1400
Provider Business Practice Location Address Fax Number:
636-441-3262
Provider Enumeration Date:
09/22/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 101YP2500X , with the licence number:  002586 , registered in the state of MO ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 493840425 , issued by the state of ( MO ) . This identifiers is of the category "MEDICAID".