Healthcare Provider Details

I. General information

NPI: 1760468375
Provider Name (Legal Business Name): KELLY D TUCKER BERNAL LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: KELLY BERNAL

II. Dates (important events)

Enumeration Date: 12/16/2005
Last Update Date: 03/27/2026
Certification Date: 03/27/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1103 WEBER RD
FARMINGTON MO
63640-3345
US

IV. Provider business mailing address

PO BOX 844715
KANSAS CITY MO
64184-4715
US

V. Phone/Fax

Practice location:
  • Phone: 573-664-1629
  • Fax: 573-431-6580
Mailing address:
  • Phone: 417-761-5214
  • Fax: 417-761-5065

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number2016042812
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: