Provider Demographics
NPI:1376295683
Name:DEITRICH, KELLIE ELAINE (MS)
Entity Type:Individual
Prefix:
First Name:KELLIE
Middle Name:ELAINE
Last Name:DEITRICH
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:800 MARY AVE
Mailing Address - Street 2:
Mailing Address - City:REEDSBURG
Mailing Address - State:WI
Mailing Address - Zip Code:53959-1119
Mailing Address - Country:US
Mailing Address - Phone:608-415-7187
Mailing Address - Fax:
Practice Address - Street 1:2155 E MAIN ST
Practice Address - Street 2:
Practice Address - City:REEDSBURG
Practice Address - State:WI
Practice Address - Zip Code:53959-9440
Practice Address - Country:US
Practice Address - Phone:608-415-9956
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-01-19
Last Update Date:2022-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI5124-226101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor