Provider Demographics
NPI:1023705845
Name:KREITER PENNING, KELLY JEAN
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:JEAN
Last Name:KREITER PENNING
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1640 WISCONSIN ST
Mailing Address - Street 2:
Mailing Address - City:LE CLAIRE
Mailing Address - State:IA
Mailing Address - Zip Code:52753-9615
Mailing Address - Country:US
Mailing Address - Phone:563-528-1708
Mailing Address - Fax:
Practice Address - Street 1:2800 EASTERN AVE
Practice Address - Street 2:
Practice Address - City:DAVENPORT
Practice Address - State:IA
Practice Address - Zip Code:52803-2012
Practice Address - Country:US
Practice Address - Phone:563-326-6431
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-04-21
Last Update Date:2023-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA118672101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health