Healthcare Provider Details

I. General information

NPI: 1891612982
Provider Name (Legal Business Name): KELLY WILLIAMS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/30/2026
Last Update Date: 06/30/2026
Certification Date: 07/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17885 HART PINKSTON RD
FARMINGTON MO
63640-3523
US

IV. Provider business mailing address

17885 HART PINKSTON RD
FARMINGTON MO
63640-3523
US

V. Phone/Fax

Practice location:
  • Phone: 573-747-9115
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number2026030047
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: