Provider Demographics
NPI:1912215070
Name:PULLEN, KELLY ANN MARIE (MSSW, LCSW)
Entity Type:Individual
Prefix:MRS
First Name:KELLY
Middle Name:ANN MARIE
Last Name:PULLEN
Suffix:
Gender:F
Credentials:MSSW, LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2411 BRANNING RD
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40222-6228
Mailing Address - Country:US
Mailing Address - Phone:502-802-5205
Mailing Address - Fax:
Practice Address - Street 1:1100 E MARKET ST
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40206-1838
Practice Address - Country:US
Practice Address - Phone:502-596-1217
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-09-22
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY5827104100000X
KY37451041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100303920Medicaid