Healthcare Provider Details

I. General information

NPI: 1790462117
Provider Name (Legal Business Name): COLBY LYNN KELLEY LSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/28/2023
Last Update Date: 04/06/2026
Certification Date: 04/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

515 N JEFFERSON AVE
SAINT LOUIS MO
63103-3000
US

IV. Provider business mailing address

515 N JEFFERSON AVE
SAINT LOUIS MO
63103-3000
US

V. Phone/Fax

Practice location:
  • Phone: 314-482-0765
  • Fax: 314-289-6543
Mailing address:
  • Phone: 314-482-0765
  • Fax: 314-289-6543

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number150.112789
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: