Provider Demographics
NPI:1285460618
Name:KUMMER, KELLIE
Entity type:Individual
Prefix:
First Name:KELLIE
Middle Name:
Last Name:KUMMER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:234 GREENBRIAR RD
Mailing Address - Street 2:
Mailing Address - City:HANOVER
Mailing Address - State:IN
Mailing Address - Zip Code:47243-9640
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2420 WILSON AVE
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:IN
Practice Address - Zip Code:47250-2135
Practice Address - Country:US
Practice Address - Phone:812-265-8226
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-09-11
Last Update Date:2024-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12474982103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst