Healthcare Provider Details

I. General information

NPI: 1902857956
Provider Name (Legal Business Name): AMY KAELKE LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/15/2006
Last Update Date: 11/07/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1107 BROADWAY ST
LAMAR MO
64759-1758
US

IV. Provider business mailing address

1107 BROADWAY ST
LAMAR MO
64759-1758
US

V. Phone/Fax

Practice location:
  • Phone: 417-682-5757
  • Fax: 417-682-5757
Mailing address:
  • Phone: 417-682-5757
  • Fax: 417-682-5757

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number2005034483
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: