Healthcare Provider Details

I. General information

NPI: 1780112771
Provider Name (Legal Business Name): KELLY CRISMON LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/02/2017
Last Update Date: 07/28/2023
Certification Date: 12/03/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4130 LINDELL BLVD
SAINT LOUIS MO
63108-2914
US

IV. Provider business mailing address

9666 OLIVE BLVD
SAINT LOUIS MO
63132-3013
US

V. Phone/Fax

Practice location:
  • Phone: 314-535-5600
  • Fax:
Mailing address:
  • Phone: 314-527-3052
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number9880
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number2017001452
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: