=====================================================
General NPI Number Information
=====================================================
NPI Number | 1083937023
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | M. ELIZABETH KINGSLEY, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/04/2010
-----------------------------------------------------
Last Update Date | 07/24/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 7611 STATE LINE RD STE. 226
-----------------------------------------------------
City | KANSAS CITY
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 64114-6801
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 816-753-7071
-----------------------------------------------------
Fax | 816-926-9180
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 7611 STATE LINE RD STE. 226
-----------------------------------------------------
City | KANSAS CITY
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 64114-6801
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 816-753-7071
-----------------------------------------------------
Fax | 816-926-9180
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CREDENTIALS COORDINATOR
-----------------------------------------------------
Name | JUDY FITCH
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 913-851-7780
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 106H00000X
-----------------------------------------------------
Taxonomy Name | Marriage & Family Therapist
-----------------------------------------------------
License Number | 300045
-----------------------------------------------------
License Number State | MO
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 106H00000X
-----------------------------------------------------
Taxonomy Name | Marriage & Family Therapist
-----------------------------------------------------
License Number | 084
-----------------------------------------------------
License Number State | KS
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 103T00000X
-----------------------------------------------------
Taxonomy Name | Psychologist
-----------------------------------------------------
License Number | 00281
-----------------------------------------------------
License Number State | MO
-----------------------------------------------------