Provider Demographics
NPI:1043485337
Name:SLAGLE, KELLI LEA (MS)
Entity type:Individual
Prefix:
First Name:KELLI
Middle Name:LEA
Last Name:SLAGLE
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:KELLI
Other - Middle Name:LEA
Other - Last Name:SMITH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MS
Mailing Address - Street 1:9802 NICHOLAS ST STE 350
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68114-2106
Mailing Address - Country:US
Mailing Address - Phone:402-932-2296
Mailing Address - Fax:402-281-0665
Practice Address - Street 1:9802 NICHOLAS ST STE 350
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68114-2106
Practice Address - Country:US
Practice Address - Phone:402-932-2296
Practice Address - Fax:402-281-0665
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-28
Last Update Date:2023-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA00982101YM0800X
NE2875101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA20-0637558Medicaid