Basic Information
| Provider Information | |||||||||
| NPI: | 1386809218 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ELEDGE | ||||||||
| FirstName: | KELLY | ||||||||
| MiddleName: | MARIE | ||||||||
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| Credential: | LCSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2885 W BATTLEFIELD ST | ||||||||
| Address2: | |||||||||
| City: | SPRINGFIELD | ||||||||
| State: | MO | ||||||||
| PostalCode: | 658073952 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4177615000 | ||||||||
| FaxNumber: | 4177615011 | ||||||||
| Practice Location | |||||||||
| Address1: | 3895 GEORGE ANDERSON RD | ||||||||
| Address2: | |||||||||
| City: | SPRINGDALE | ||||||||
| State: | AR | ||||||||
| PostalCode: | 727648251 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4795211532 | ||||||||
| FaxNumber: | 4795219940 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/21/2008 | ||||||||
| LastUpdateDate: | 10/20/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/20/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 2020028052 | MO | N | Behavioral Health & Social Service Providers | Social Worker | Clinical | 1041C0700X | 7268-C | AR | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.