Provider Demographics
NPI:1508374299
Name:PETTY, KELSEY
Entity Type:Individual
Prefix:
First Name:KELSEY
Middle Name:
Last Name:PETTY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:KELSEY
Other - Middle Name:
Other - Last Name:MOSS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:101 NOAHS LANE
Mailing Address - Street 2:
Mailing Address - City:JEFFERSONVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:47130
Mailing Address - Country:US
Mailing Address - Phone:812-284-1760
Mailing Address - Fax:812-282-8636
Practice Address - Street 1:101 NOAHS LANE
Practice Address - Street 2:
Practice Address - City:JEFFERSONVILLE
Practice Address - State:IN
Practice Address - Zip Code:47130
Practice Address - Country:US
Practice Address - Phone:812-284-1760
Practice Address - Fax:812-282-8636
Is Sole Proprietor?:No
Enumeration Date:2018-01-16
Last Update Date:2018-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker