=====================================================
General NPI Number Information
=====================================================
NPI Number | 1225570880
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | KELLY O'DONNELL COUNSELING, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/14/2016
-----------------------------------------------------
Last Update Date | 11/14/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 456 N NEW BALLAS RD STE 369
-----------------------------------------------------
City | SAINT LOUIS
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 63141-6846
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 314-643-8224
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 456 N NEW BALLAS RD STE 369
-----------------------------------------------------
City | SAINT LOUIS
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 63141-6846
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 314-643-8224
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | LICENSED CLINICAL SOCIAL WORKER
-----------------------------------------------------
Name | KELLY BETH O'DONNELL
-----------------------------------------------------
Credential | LCSW
-----------------------------------------------------
Telephone | 314-643-8224
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | 2015039713
-----------------------------------------------------
License Number State | MO
-----------------------------------------------------