Provider Demographics
NPI:1568233278
Name:PENCE, KELLY R
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:R
Last Name:PENCE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1501 ANDERSON DR
Mailing Address - Street 2:
Mailing Address - City:GARRETT
Mailing Address - State:IN
Mailing Address - Zip Code:46738-2062
Mailing Address - Country:US
Mailing Address - Phone:260-226-2176
Mailing Address - Fax:
Practice Address - Street 1:1501 ANDERSON DR
Practice Address - Street 2:
Practice Address - City:GARRETT
Practice Address - State:IN
Practice Address - Zip Code:46738-2062
Practice Address - Country:US
Practice Address - Phone:260-226-2176
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-01-11
Last Update Date:2024-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Multi-Specialty