Healthcare Provider Details

I. General information

NPI: 1992174445
Provider Name (Legal Business Name): KELLI COBLE LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/15/2015
Last Update Date: 09/15/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2411 W CATALPA ST
SPRINGFIELD MO
65807-1123
US

IV. Provider business mailing address

900 E LAHARPE ST
KIRKSVILLE MO
63501-4520
US

V. Phone/Fax

Practice location:
  • Phone: 417-862-3455
  • Fax: 417-862-9771
Mailing address:
  • Phone: 660-665-1962
  • Fax: 660-665-3989

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number2012004884
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: