Provider Demographics
NPI:1669751160
Name:PETACCIO, KELLY REBECCA (MS LPC CPCS)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:REBECCA
Last Name:PETACCIO
Suffix:
Gender:F
Credentials:MS LPC CPCS
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:REBECCA
Other - Last Name:WEISTER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:130 GOVERNORS SQ STE B
Mailing Address - Street 2:
Mailing Address - City:PEACHTREE CITY
Mailing Address - State:GA
Mailing Address - Zip Code:30269-4862
Mailing Address - Country:US
Mailing Address - Phone:770-519-2743
Mailing Address - Fax:
Practice Address - Street 1:130 GOVERNORS SQ STE B
Practice Address - Street 2:
Practice Address - City:PEACHTREE CITY
Practice Address - State:GA
Practice Address - Zip Code:30269-4862
Practice Address - Country:US
Practice Address - Phone:770-519-2743
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-08-15
Last Update Date:2020-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
GALPC008109101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA1457876906OtherTHE CENTER FOR LIVING BALANCE