Provider Demographics
NPI:1760464572
Name:VALENTINE, KELLIE LEE
Entity Type:Individual
Prefix:
First Name:KELLIE
Middle Name:LEE
Last Name:VALENTINE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:KELLIE
Other - Middle Name:LEE
Other - Last Name:VALENTINE-ANDREWS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:208 E BAYFRONT PKWY STE 200B
Mailing Address - Street 2:
Mailing Address - City:ERIE
Mailing Address - State:PA
Mailing Address - Zip Code:16507-2413
Mailing Address - Country:US
Mailing Address - Phone:814-871-6333
Mailing Address - Fax:814-871-6335
Practice Address - Street 1:208 E BAYFRONT PKWY STE 200B
Practice Address - Street 2:
Practice Address - City:ERIE
Practice Address - State:PA
Practice Address - Zip Code:16507-2413
Practice Address - Country:US
Practice Address - Phone:814-871-6333
Practice Address - Fax:814-871-6335
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-17
Last Update Date:2019-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPC003951101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA102667010002Medicaid