MEDICARE: JOHANNA EILEEN KELLEY LCSW, LSCSW

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker	06375	KS
2	1041C0700X	Clinical Social Worker	2023044019	MO

General Provider Information

NPI Number	:	1669144606
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JOHANNA EILEEN KELLEY LCSW, LSCSW

Provider Business Mailing Address
First Line	:	2108 W 75TH ST # 401
Second Line	:
City	:	PRAIRIE VILLAGE
State	:	KS
Zip	:	66208-3503
Country	:	US
Telephone Number	:	816-388-0370
Fax Number	:

Provider Business Practice Location Address
First Line	:	2108 W 75TH ST # 401
Second Line	:
City	:	PRAIRIE VILLAGE
State	:	KS
Zip	:	66208-3503
Country	:	US
Telephone Number	:	816-388-0370
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/28/2021
Last Update Date	:	11/19/2025

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