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Individual
KELLY REBECCA PETACCIO
Active
Individual
KELLY REBECCA PETACCIO
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Credential
MS LPC CPCS
Taxonomy
Speciality
Code
Description
License number
State
101YM0800X
Mental Health Counselor
Primary
LPC008109
GA
101YM0800X
Mental Health Counselor
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
1457876906
THE CENTER FOR LIVING BALANCE
GA
Enumeration date
08/15/2011
Last updated
01/27/2020
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