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NPI Code Detail

MEDICARE: MS. KELLIE N PETTY

MEDICARE: MS. KELLIE N PETTY
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
1222Q00000XDevelopmental Therapist

General Provider Information

NPI Number : 1619121191
Entity Type Code : Individual
Provider Name (Legal Business Name) : MS. KELLIE N PETTY
Provider Business Mailing Address
First Line : 3440 S COTTAGE GROVE AVE
Second Line : 1203
City : CHICAGO
State : IL
Zip : 60616-4140
Country : US
Telephone Number :
Fax Number :
Provider Business Practice Location Address
First Line : 3440 S COTTAGE GROVE AVE
Second Line : 1203
City : CHICAGO
State : IL
Zip : 60616-4140
Country : US
Telephone Number : 773-535-3471
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 11/10/2008
Last Update Date : 11/10/2008

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