Healthcare Provider Details

I. General information

NPI: 1750301784
Provider Name (Legal Business Name): KELLEY RENEE REED L.C.S.W.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/20/2006
Last Update Date: 05/21/2025
Certification Date: 05/21/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

603 SOUTH JEFFERSON STREET
AVA MO
65608
US

IV. Provider business mailing address

RR 1 BOX 54B
MOUNTAIN GROVE MO
65711-9519
US

V. Phone/Fax

Practice location:
  • Phone: 417-683-3398
  • Fax:
Mailing address:
  • Phone: 417-259-9644
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number004904
License Number StateMO

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier493947717
Identifier TypeMEDICAID
Identifier StateMO
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: