Basic Information
| Provider Information | |||||||||
| NPI: | 1407453178 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PHILLIPS | ||||||||
| FirstName: | KELLY | ||||||||
| MiddleName: | R. | ||||||||
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| Credential: | LMSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3801 BLUE PKWY | ||||||||
| Address2: | |||||||||
| City: | KANSAS CITY | ||||||||
| State: | MO | ||||||||
| PostalCode: | 641302807 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8165995267 | ||||||||
| FaxNumber: | 8165995951 | ||||||||
| Practice Location | |||||||||
| Address1: | 501 N SUNSET LN | ||||||||
| Address2: | |||||||||
| City: | RAYMORE | ||||||||
| State: | MO | ||||||||
| PostalCode: | 640836408 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8448538937 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/06/2020 | ||||||||
| LastUpdateDate: | 11/03/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 11/03/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X | 2020018075 | MO | Y | Behavioral Health & Social Service Providers | Social Worker |
ID Information
| ID | Type | State | Issuer | Description | 2020018075 | 01 | MO | STATE LICENSE | OTHER |