Provider Demographics
NPI:1679224257
Name:LEVERIDGE, KELSEY D
Entity Type:Individual
Prefix:
First Name:KELSEY
Middle Name:D
Last Name:LEVERIDGE
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:PO BOX 2011
Mailing Address - Street 2:
Mailing Address - City:HAZARD
Mailing Address - State:KY
Mailing Address - Zip Code:41702-2011
Mailing Address - Country:US
Mailing Address - Phone:606-435-7557
Mailing Address - Fax:606-435-7558
Practice Address - Street 1:101 TOWN AND COUNTRY LN STE 106
Practice Address - Street 2:
Practice Address - City:HAZARD
Practice Address - State:KY
Practice Address - Zip Code:41701-9524
Practice Address - Country:US
Practice Address - Phone:606-435-7557
Practice Address - Fax:606-435-7558
Is Sole Proprietor?:No
Enumeration Date:2022-01-14
Last Update Date:2024-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY260760101Y00000X
KY277285101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100815470Medicaid