Provider Demographics
NPI:1104588177
Name:YOUNG, KELLY JANE (CRADC)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:JANE
Last Name:YOUNG
Suffix:
Gender:F
Credentials:CRADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:501 S PENNSYLVANIA AVE
Mailing Address - Street 2:
Mailing Address - City:JOPLIN
Mailing Address - State:MO
Mailing Address - Zip Code:64801-2286
Mailing Address - Country:US
Mailing Address - Phone:417-553-0043
Mailing Address - Fax:417-553-0081
Practice Address - Street 1:501 S PENNSYLVANIA AVE
Practice Address - Street 2:
Practice Address - City:JOPLIN
Practice Address - State:MO
Practice Address - Zip Code:64801-2286
Practice Address - Country:US
Practice Address - Phone:417-553-0043
Practice Address - Fax:417-553-0081
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-07
Last Update Date:2021-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO4486101YA0400X
10017175T00000X
MO2821261QM0850X, 261QM0855X, 261QR0405X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Single Specialty
No175T00000XOther Service ProvidersPeer Specialist
No261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
No261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health