Basic Information
| Provider Information | |||||||||
| NPI: | 1134207269 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | IRVINE | ||||||||
| FirstName: | KELLY | ||||||||
| MiddleName: | L. | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PSYD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | MOYNIHAN | ||||||||
| OtherFirstName: | KELLY | ||||||||
| OtherMiddleName: | L. | ||||||||
| OtherNamePrefix: | DR. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | PSYD | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1800 COMMUNITY | ||||||||
| Address2: | |||||||||
| City: | CLINTON | ||||||||
| State: | MO | ||||||||
| PostalCode: | 647358804 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6608908156 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1000 W NIFONG BLVD BLDG 6 | ||||||||
| Address2: | |||||||||
| City: | COLUMBIA | ||||||||
| State: | MO | ||||||||
| PostalCode: | 652035615 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8884031071 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/02/2006 | ||||||||
| LastUpdateDate: | 08/28/2019 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TB0200X | 2018042229 | MO | Y | Behavioral Health & Social Service Providers | Psychologist | Cognitive & Behavioral |
ID Information
| ID | Type | State | Issuer | Description | 50583 | 01 | NRHSP IN PSYCH | OTHER | NATIONAL REGISTER # | 01 | AZ | 50583 | OTHER | APA MEMBERSHIP # | 01 | AZ | 69103091 | OTHER | AZ0616050 | 01 | AZ | BC/BS | OTHER | 116730 | 01 | AZ | BHN | OTHER | 5457314 | 01 | AZ | FIRST HEALTH/CNN | OTHER | 415 | 01 | IA | IA HSP # | OTHER | 141592 | 05 | LA | MEDICAID | 803925 | 05 | AZ | MEDICAID | 2128566 | 01 | AZ | CIGNA | OTHER | 228289 | 01 | AZ | ONE HEALTH & GWL | OTHER | 291968 | 01 | AZ | MHN | OTHER | 4142 | 01 | CPQ | OTHER | 86-1043861 | 01 | AZ | MAGELAN, BIODYNE, AETNA | OTHER |