MEDICARE: KEISHA PETTIJOHN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker
2	171M00000X	Case Manager/Care Coordinator

General Provider Information

NPI Number	:	1528487154
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KEISHA PETTIJOHN

Provider Business Mailing Address
First Line	:	PO BOX 12685
Second Line	:
City	:	CINCINNATI
State	:	OH
Zip	:	45212-0685
Country	:	US
Telephone Number	:	513-549-4172
Fax Number	:

Provider Business Practice Location Address
First Line	:	2601 MELROSE AVE
Second Line	:
City	:	CINCINNATI
State	:	OH
Zip	:	45206-1601
Country	:	US
Telephone Number	:	513-549-4172
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/10/2014
Last Update Date	:	11/05/2020

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