Provider Demographics
NPI:1720593312
Name:PICHOTTA, KELLY LYNN (LCDC III)
Entity Type:Individual
Prefix:MS
First Name:KELLY
Middle Name:LYNN
Last Name:PICHOTTA
Suffix:
Gender:F
Credentials:LCDC III
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:178 PITTY PAT LN
Mailing Address - Street 2:
Mailing Address - City:WALTON
Mailing Address - State:KY
Mailing Address - Zip Code:41094-7239
Mailing Address - Country:US
Mailing Address - Phone:859-638-6502
Mailing Address - Fax:
Practice Address - Street 1:178 PITTY PAT LN
Practice Address - Street 2:
Practice Address - City:WALTON
Practice Address - State:KY
Practice Address - Zip Code:41094-7239
Practice Address - Country:US
Practice Address - Phone:859-638-6502
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-12-05
Last Update Date:2017-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHLCDCIII.161363101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)