Healthcare Provider Details

I. General information

NPI: 1730014200
Provider Name (Legal Business Name): KIM KELLY PHD, LPC, NCC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/16/2026
Last Update Date: 06/16/2026
Certification Date: 06/16/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2926 LEMP AVE
SAINT LOUIS MO
63118-1716
US

IV. Provider business mailing address

2926 LEMP AVE
SAINT LOUIS MO
63118-1716
US

V. Phone/Fax

Practice location:
  • Phone: 904-624-0140
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number2026024914
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: