Provider Demographics
NPI:1922311984
Name:WALETICH, BRITTANY ELLYCE (CRC)
Entity Type:Individual
Prefix:
First Name:BRITTANY
Middle Name:ELLYCE
Last Name:WALETICH
Suffix:
Gender:F
Credentials:CRC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2412 GREATSTONE PT
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40504-3274
Mailing Address - Country:US
Mailing Address - Phone:859-224-4081
Mailing Address - Fax:859-224-4082
Practice Address - Street 1:800 W WOODLAWN AVE
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40215-2472
Practice Address - Country:US
Practice Address - Phone:502-409-7181
Practice Address - Fax:888-450-0935
Is Sole Proprietor?:Yes
Enumeration Date:2010-07-20
Last Update Date:2021-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY273867103K00000X
171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No171M00000XOther Service ProvidersCase Manager/Care Coordinator