Healthcare Provider Details

I. General information

NPI: 1356267850
Provider Name (Legal Business Name): KALEN GRACE LUECKE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/29/2026
Last Update Date: 06/29/2026
Certification Date: 06/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

118 W 5TH ST
FULTON MO
65251-1735
US

IV. Provider business mailing address

210 EL MERCADO PLZ
JEFFERSON CITY MO
65109-6822
US

V. Phone/Fax

Practice location:
  • Phone: 573-680-4913
  • Fax:
Mailing address:
  • Phone: 573-680-4913
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number2026028973
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: