Provider Demographics
NPI:1780630756
Name:CALLERY, PATRICE R (LPCC)
Entity Type:Individual
Prefix:
First Name:PATRICE
Middle Name:R
Last Name:CALLERY
Suffix:
Gender:F
Credentials:LPCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:503 FARRELL DR
Mailing Address - Street 2:
Mailing Address - City:COVINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:41011-3775
Mailing Address - Country:US
Mailing Address - Phone:859-331-3292
Mailing Address - Fax:859-578-3242
Practice Address - Street 1:7459 BURLINGTON PIKE
Practice Address - Street 2:
Practice Address - City:FLORENCE
Practice Address - State:KY
Practice Address - Zip Code:41042-1553
Practice Address - Country:US
Practice Address - Phone:859-331-3292
Practice Address - Fax:859-578-3242
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-25
Last Update Date:2024-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY1121101YP2500X
KY104016101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY610661458OtherFEDERAL TAX ID NUMBER