Healthcare Provider Details

I. General information

NPI: 1902123201
Provider Name (Legal Business Name): KELLY J WEDDLE LMFT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: KELLY J BLACK

II. Dates (important events)

Enumeration Date: 04/26/2010
Last Update Date: 09/01/2023
Certification Date: 08/18/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

925 S LINCOLN BLVD
HODGENVILLE KY
42748-1701
US

IV. Provider business mailing address

PO BOX 1080
BURKESVILLE KY
42717-1080
US

V. Phone/Fax

Practice location:
  • Phone: 844-435-0900
  • Fax: 270-858-4029
Mailing address:
  • Phone: 270-858-6655
  • Fax: 270-858-4607

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number276325
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: