Provider Demographics
NPI:1861769614
Name:WHEELER, KERRY
Entity type:Individual
Prefix:
First Name:KERRY
Middle Name:
Last Name:WHEELER
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:PO BOX 790
Mailing Address - Street 2:
Mailing Address - City:ASHLAND
Mailing Address - State:KY
Mailing Address - Zip Code:41105-0790
Mailing Address - Country:US
Mailing Address - Phone:606-329-8588
Mailing Address - Fax:606-329-8195
Practice Address - Street 1:6500 HWY 645
Practice Address - Street 2:
Practice Address - City:INEZ
Practice Address - State:KY
Practice Address - Zip Code:41224
Practice Address - Country:US
Practice Address - Phone:606-534-4002
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-11-22
Last Update Date:2020-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS162784101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY30610026Medicaid