Healthcare Provider Details

I. General information

NPI: 1083937023
Provider Name (Legal Business Name): M. ELIZABETH KINGSLEY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/04/2010
Last Update Date: 07/24/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7611 STATE LINE RD STE. 226
KANSAS CITY MO
64114-6801
US

IV. Provider business mailing address

7611 STATE LINE RD STE. 226
KANSAS CITY MO
64114-6801
US

V. Phone/Fax

Practice location:
  • Phone: 816-753-7071
  • Fax: 816-926-9180
Mailing address:
  • Phone: 816-753-7071
  • Fax: 816-926-9180

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number00281
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number300045
License Number StateMO
# 3
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number084
License Number StateKS

VIII. Authorized Official

Name: JUDY FITCH
Title or Position: CREDENTIALS COORDINATOR
Credential:
Phone: 913-851-7780