Provider Demographics
NPI:1760159875
Name:WEINTRAUB, KERRY A
Entity Type:Individual
Prefix:
First Name:KERRY
Middle Name:A
Last Name:WEINTRAUB
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 1:151 PORTOBELLO RD
Mailing Address - Street 2:
Mailing Address - City:RADCLIFF
Mailing Address - State:KY
Mailing Address - Zip Code:40160-8933
Mailing Address - Country:US
Mailing Address - Phone:253-306-6918
Mailing Address - Fax:
Practice Address - Street 1:100 DIECKS DR
Practice Address - Street 2:
Practice Address - City:ELIZABETHTOWN
Practice Address - State:KY
Practice Address - Zip Code:42701-2443
Practice Address - Country:US
Practice Address - Phone:270-982-1253
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-26
Last Update Date:2021-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY255349104100000X
KY256121104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker