Provider Demographics
NPI:1992117881
Name:DURBIN, KELLY DENISE (LCSW)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:DENISE
Last Name:DURBIN
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1223 BAKEWELL DR
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63137-2129
Mailing Address - Country:US
Mailing Address - Phone:314-265-4054
Mailing Address - Fax:
Practice Address - Street 1:1920 S 7TH ST
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63104
Practice Address - Country:US
Practice Address - Phone:314-502-9269
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-05-27
Last Update Date:2014-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1490067411041C0700X
MO200220163851041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical