Provider Demographics
NPI:1902123201
Name:WEDDLE, KELLY J (LMFT)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:J
Last Name:WEDDLE
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:J
Other - Last Name:BLACK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 1080
Mailing Address - Street 2:
Mailing Address - City:BURKESVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:42717-1080
Mailing Address - Country:US
Mailing Address - Phone:270-858-6655
Mailing Address - Fax:270-858-4607
Practice Address - Street 1:925 S LINCOLN BLVD
Practice Address - Street 2:
Practice Address - City:HODGENVILLE
Practice Address - State:KY
Practice Address - Zip Code:42748-1701
Practice Address - Country:US
Practice Address - Phone:844-435-0900
Practice Address - Fax:270-858-4029
Is Sole Proprietor?:No
Enumeration Date:2010-04-26
Last Update Date:2023-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY276325106H00000X
260269101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100811660Medicaid
KY15540976OtherCAQH