Provider Demographics
NPI:1710228697
Name:PELLERITO, IVY S (MA, LPC)
Entity Type:Individual
Prefix:MS
First Name:IVY
Middle Name:S
Last Name:PELLERITO
Suffix:
Gender:F
Credentials:MA, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:208 SE 3RD ST STE 2
Mailing Address - Street 2:
Mailing Address - City:LEES SUMMIT
Mailing Address - State:MO
Mailing Address - Zip Code:64063-2762
Mailing Address - Country:US
Mailing Address - Phone:816-427-1828
Mailing Address - Fax:
Practice Address - Street 1:208 SE 3RD ST STE 2
Practice Address - Street 2:
Practice Address - City:LEES SUMMIT
Practice Address - State:MO
Practice Address - Zip Code:64063-2762
Practice Address - Country:US
Practice Address - Phone:816-427-1828
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-03-03
Last Update Date:2021-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20004023896101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional