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General NPI Number Information
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NPI Number | 1780112771
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Entity Type | Individual
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Provider Name | KELLY CRISMON LCSW
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Gender | Female
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Dates
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Enumeration Date | 06/02/2017
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Last Update Date | 07/28/2023
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Provider Practice Location Address
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Address Line | 4130 LINDELL BLVD
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City | SAINT LOUIS
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State | MO
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Zip | 63108-2914
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Country | US
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Telephone | 314-535-5600
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Fax |
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Provider Business Mailing Address
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Address Line | 9666 OLIVE BLVD
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City | SAINT LOUIS
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State | MO
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Zip | 63132-3013
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Country | US
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Telephone | 314-527-3052
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YA0400X
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Taxonomy Name | Addiction (Substance Use Disorder) Counselor
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License Number | 9880
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License Number State | MO
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Taxonomy #2
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Taxonomy Code | 104100000X
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Taxonomy Name | Social Worker
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License Number | 2017001452
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License Number State | MO
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