Provider Demographics
NPI:1275886780
Name:PAINTER, KELLY J (LSW,MAT, ATR-BC)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:J
Last Name:PAINTER
Suffix:
Gender:F
Credentials:LSW,MAT, ATR-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8363 OLD STAGE RD
Mailing Address - Street 2:
Mailing Address - City:WAYNESVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:45068-9744
Mailing Address - Country:US
Mailing Address - Phone:937-414-2325
Mailing Address - Fax:
Practice Address - Street 1:1349 E STROOP RD
Practice Address - Street 2:
Practice Address - City:KETTERING
Practice Address - State:OH
Practice Address - Zip Code:45429-4925
Practice Address - Country:US
Practice Address - Phone:937-293-1115
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-10-22
Last Update Date:2012-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH0021881104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker