Provider Demographics
NPI:1255928578
Name:KANELOS, JUDY A (EXECUTIVE DIRECTOR)
Entity type:Individual
Prefix:
First Name:JUDY
Middle Name:A
Last Name:KANELOS
Suffix:
Gender:F
Credentials:EXECUTIVE DIRECTOR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1251 W BROADWAY ST STE A
Mailing Address - Street 2:
Mailing Address - City:MONTICELLO
Mailing Address - State:IN
Mailing Address - Zip Code:47960-1880
Mailing Address - Country:US
Mailing Address - Phone:574-218-0926
Mailing Address - Fax:
Practice Address - Street 1:1251 W BROADWAY ST STE A
Practice Address - Street 2:
Practice Address - City:MONTICELLO
Practice Address - State:IN
Practice Address - Zip Code:47960-1880
Practice Address - Country:US
Practice Address - Phone:574-218-0926
Practice Address - Fax:574-583-2600
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-22
Last Update Date:2020-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN20-014239253Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN82-1347916Medicaid