Kelly Rae Staddie, LCSW

Primary specialty

Clinical Social WorkerTaxonomy code 1041C0700X

License

2005008356 Issued in MO

Practice address

734 W Monroe St
Mexico, MO 65265-1970

Phone

(573) 642-5345

Fax

(573) 642-5162

NPI assigned

Dec 19, 2006

Sex

Female

Sole proprietor

No

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 1

Addresses

Other names 1

• Miss Kelly Rae Sportsman Professional name

Medicare fee-for-service enrollment

Not listed in the public Medicare enrollment file

Medicare enrollment (NPD)

Enrolled

Interoperability endpoints

• Direct secure messaging: kelly.staddie.1@30520.direct.athenahealth.com

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1166486400000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1183852800000",
    "number": "1093879835",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "24 LAKESIDE PL",
            "city": "MEXICO",
            "state": "MO",
            "postal_code": "652652227",
            "telephone_number": "573-582-7866"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "734 W MONROE ST",
            "city": "MEXICO",
            "state": "MO",
            "postal_code": "652651970",
            "telephone_number": "573-642-5345",
            "fax_number": "573-642-5162"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "STADDIE",
        "first_name": "KELLY",
        "middle_name": "RAE",
        "name_prefix": "Mrs.",
        "credential": "LCSW",
        "sole_proprietor": "NO",
        "sex": "F",
        "enumeration_date": "2006-12-19",
        "last_updated": "2007-07-08",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "1041C0700X",
            "taxonomy_group": "",
            "desc": "Social Worker, Clinical",
            "state": "MO",
            "license": "2005008356",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "first_name": "KELLY",
            "last_name": "SPORTSMAN",
            "middle_name": "RAE",
            "prefix": "MISS",
            "code": "2",
            "type": "Professional Name"
        }
    ]
}

• SSM Audrain Health Care, Inc.
• SSM Audrain Health Care, Inc.
• SSM Audrain Health Care, Inc.
• SSM Health Businesses
• SSM Health Businesses
• Kimberly L. Stanley
• Edward G. Stephens, D.D.S.
• Madison Breanne Sturrock, LMSW
• Sun Lakes Physical Therapy
• Jennifer Sutterer, MA, CCC-SLP

• Clinical Social Worker in Mexico, MO
• Providers in Mexico, MO by specialty
• Clinical Social Worker in Missouri

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jul 8, 2007; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.