Healthcare Provider Details

I. General information

NPI: 1104588177
Provider Name (Legal Business Name): KELLY JANE YOUNG CRADC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/07/2021
Last Update Date: 10/07/2021
Certification Date: 10/07/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

501 S PENNSYLVANIA AVE
JOPLIN MO
64801-2286
US

IV. Provider business mailing address

501 S PENNSYLVANIA AVE
JOPLIN MO
64801-2286
US

V. Phone/Fax

Practice location:
  • Phone: 417-553-0043
  • Fax: 417-553-0081
Mailing address:
  • Phone: 417-553-0043
  • Fax: 417-553-0081

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number2821
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number2821
License Number StateMO
# 3
Primary TaxonomyY
Taxonomy Code261QR0405X
TaxonomySubstance Use Disorder Rehabilitation Clinic/Center
License Number2821
License Number StateMO
# 4
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number4486
License Number StateMO
# 5
Primary TaxonomyN
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License Number10017
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: