Healthcare Provider Details

I. General information

NPI: 1669144606
Provider Name (Legal Business Name): JOHANNA EILEEN KELLEY LCSW, LSCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/28/2021
Last Update Date: 08/25/2026
Certification Date: 08/25/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

751 E 63RD ST STE 217C
KANSAS CITY MO
64110-3385
US

IV. Provider business mailing address

751 E 63RD ST STE 217C
KANSAS CITY MO
64110-3385
US

V. Phone/Fax

Practice location:
  • Phone: 816-388-0370
  • Fax:
Mailing address:
  • Phone: 816-388-0370
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number2023044019
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number06375
License Number StateKS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: