Provider Demographics
NPI:1851794200
Name:PACICCO, KELLI (MA, LAC)
Entity Type:Individual
Prefix:
First Name:KELLI
Middle Name:
Last Name:PACICCO
Suffix:
Gender:F
Credentials:MA, LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2600 E SOUTHERN AVE STE C3
Mailing Address - Street 2:
Mailing Address - City:TEMPE
Mailing Address - State:AZ
Mailing Address - Zip Code:85282-7609
Mailing Address - Country:US
Mailing Address - Phone:602-859-9744
Mailing Address - Fax:602-865-8710
Practice Address - Street 1:2600 E SOUTHERN AVE STE C3
Practice Address - Street 2:
Practice Address - City:TEMPE
Practice Address - State:AZ
Practice Address - Zip Code:85282-7609
Practice Address - Country:US
Practice Address - Phone:602-859-9744
Practice Address - Fax:602-865-8710
Is Sole Proprietor?:Yes
Enumeration Date:2014-09-30
Last Update Date:2014-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLAC-15199101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health