Provider Demographics
NPI:1538589254
Name:KENDRICK-CALLERY, PAITTON NICOLE
Entity type:Individual
Prefix:
First Name:PAITTON
Middle Name:NICOLE
Last Name:KENDRICK-CALLERY
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 1:123 HARVARD AVE
Mailing Address - Street 2:
Mailing Address - City:PUEBLO
Mailing Address - State:CO
Mailing Address - Zip Code:81004-1223
Mailing Address - Country:US
Mailing Address - Phone:918-658-8352
Mailing Address - Fax:
Practice Address - Street 1:123 HARVARD AVE
Practice Address - Street 2:
Practice Address - City:PUEBLO
Practice Address - State:CO
Practice Address - Zip Code:81004-1223
Practice Address - Country:US
Practice Address - Phone:918-658-8352
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-04-21
Last Update Date:2024-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
24-107221700000X
COLPC.0020849101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
No221700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersArt Therapist