Healthcare Provider Details

I. General information

NPI: 1134207269
Provider Name (Legal Business Name): KELLY L. IRVINE PSYD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: KELLY L. MOYNIHAN PSYD

II. Dates (important events)

Enumeration Date: 11/02/2006
Last Update Date: 08/28/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 W NIFONG BLVD BLDG 6
COLUMBIA MO
65203-5615
US

IV. Provider business mailing address

1800 COMMUNITY
CLINTON MO
64735-8804
US

V. Phone/Fax

Practice location:
  • Phone: 888-403-1071
  • Fax:
Mailing address:
  • Phone: 660-890-8156
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TB0200X
TaxonomyCognitive & Behavioral Psychologist
License Number2018042229
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: