Provider Demographics
NPI:1265556039
Name:PETRUCCI KACKLEY, ANDREA CHRISTINA (MA LPC NCC)
Entity type:Individual
Prefix:MRS
First Name:ANDREA
Middle Name:CHRISTINA
Last Name:PETRUCCI KACKLEY
Suffix:
Gender:F
Credentials:MA LPC NCC
Other - Prefix:
Other - First Name:ANDREA
Other - Middle Name:C
Other - Last Name:KACKLEY
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MA LPC NCC
Mailing Address - Street 1:2914 HEDGESVILLE ROAD
Mailing Address - Street 2:APPLE RIDGE COUNSELING ASSOCIATES
Mailing Address - City:MARTINSBURG
Mailing Address - State:WV
Mailing Address - Zip Code:25403
Mailing Address - Country:US
Mailing Address - Phone:304-754-8495
Mailing Address - Fax:
Practice Address - Street 1:2914 HEDGESVILLE ROAD
Practice Address - Street 2:APPLE RIDGE COUNSELING ASSOCIATES
Practice Address - City:MARTINSBURG
Practice Address - State:WV
Practice Address - Zip Code:25403
Practice Address - Country:US
Practice Address - Phone:304-754-8495
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV1119101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional