Healthcare Provider Details

I. General information

NPI: 1639583115
Provider Name (Legal Business Name): KELLY EGGIMANN LAC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/12/2014
Last Update Date: 06/12/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12510 W 62ND TER SUITE 109
SHAWNEE KS
66216-1802
US

IV. Provider business mailing address

130 E 5TH ST PO BOX 711
NEWTON KS
67114-2206
US

V. Phone/Fax

Practice location:
  • Phone: 913-766-1587
  • Fax: 913-766-1668
Mailing address:
  • Phone: 316-283-6743
  • Fax: 316-283-6830

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number295
License Number StateKS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: