Provider Demographics
NPI:1417413782
Name:LEAVITT, KELLY N (LSW)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:N
Last Name:LEAVITT
Suffix:
Gender:F
Credentials:LSW
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:N
Other - Last Name:HILL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LSW
Mailing Address - Street 1:315 MULBERRY ST
Mailing Address - Street 2:
Mailing Address - City:EVANSVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:47713-1252
Mailing Address - Country:US
Mailing Address - Phone:812-421-7489
Mailing Address - Fax:812-436-0209
Practice Address - Street 1:315 MULBERRY ST
Practice Address - Street 2:
Practice Address - City:EVANSVILLE
Practice Address - State:IN
Practice Address - Zip Code:47713-1252
Practice Address - Country:US
Practice Address - Phone:812-421-7489
Practice Address - Fax:812-436-0209
Is Sole Proprietor?:Yes
Enumeration Date:2019-02-12
Last Update Date:2019-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN33008191A104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes104100000XBehavioral Health & Social Service ProvidersSocial WorkerGroup - Multi-Specialty