Kelly Rebecca Petaccio, MS LPC CPCS

Primary specialty

Mental Health CounselorTaxonomy code 101YM0800X

License

LPC008109 Issued in GA

Practice address

130 Governors SQ Ste B
Peachtree City, GA 30269-4862

Phone

(770) 519-2743

NPI assigned

Aug 15, 2011

Sex

Female

Sole proprietor

Yes

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 2

Addresses

Other identifiers 1

Other names 1

• Kelly Rebecca Weister Former name

Medicare fee-for-service enrollment

Enrolled in GA

Eligible to order & refer

• Part B services: Yes
• Medical equipment: Yes
• Home health: No
• Power mobility devices: No
• Hospice: No

Green means eligible to order or refer.

Enrollment records 1

Specialty

Mental Health Counselor

Education

Other, 2007

Medicare assignment

May accept Medicare assignment

Practice addresses (Care Compare)

Medicare enrollment (NPD)

Enrolled

Credentials

Master of Science

State licenses

Practice roles

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships and National Provider Directory roles.

• Rhodium Care Group of Ga LLC

  • Psychologist
  • Jackson, GA
  • NPI 1649148859
  Medicare reassignment
• Penndel Mental Health Center

  • Mental Health Clinic/Center (Including Community Mental Health Center)
  • Langhorne, PA
  • NPI 1104096973
  NPD (past)
• Penndel Mental Health Center, Inc.

  • Community/Behavioral Health Agency
  • Penndel, PA
  • NPI 1710019096
  NPD (past)

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1313366400000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1580083200000",
    "number": "1669751160",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "130 GOVERNORS SQ STE B",
            "city": "PEACHTREE CITY",
            "state": "GA",
            "postal_code": "302694862",
            "telephone_number": "770-519-2743"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "130 GOVERNORS SQ STE B",
            "city": "PEACHTREE CITY",
            "state": "GA",
            "postal_code": "302694862",
            "telephone_number": "770-519-2743"
        }
    ],
    "practiceLocations": [
        {
            "address_1": "2005 Cabot Blvd W",
            "address_purpose": "LOCATION",
            "city": "Langhorne",
            "state": "PA",
            "postal_code": "190471885",
            "country_code": "US",
            "telephone_number": "267-587-2300",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "basic": {
        "last_name": "PETACCIO",
        "first_name": "KELLY",
        "middle_name": "REBECCA",
        "credential": "MS LPC CPCS",
        "sole_proprietor": "YES",
        "sex": "F",
        "enumeration_date": "2011-08-15",
        "last_updated": "2020-01-27",
        "certification_date": "2020-01-27",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "101YM0800X",
            "taxonomy_group": "",
            "desc": "Counselor, Mental Health",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "101YM0800X",
            "taxonomy_group": "",
            "desc": "Counselor, Mental Health",
            "state": "GA",
            "license": "LPC008109",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "THE CENTER FOR LIVING BALANCE",
            "identifier": "1457876906",
            "state": "GA"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "first_name": "KELLY",
            "last_name": "WEISTER",
            "middle_name": "REBECCA",
            "code": "1",
            "type": "Former Name"
        }
    ]
}

• Rhonda Pennypacker
• Vincent J. Perciaccante, DDS
• Kelly Rose Peronti, AGACNP-BC
• Dennis J. Perrott, D.D.S.
• Dimetrius Perrymond
• Melissa Kristine Petersen, NP
• Takana Petty
• Phalanx Med Georgia, LLC
• Pharmacy Place LLC (The Pharmacy Place)
• Pharmacy Place LLC

• Mental Health Counselor in Peachtree City, GA
• Providers in Peachtree City, GA by specialty
• Mental Health Counselor in Georgia

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jan 27, 2020; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; Order and Referring.
• Medicare Care Compare (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.