Basic Information
Provider Information
NPI: 1003293267
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: BERADUCE
FirstName: KEGAN
MiddleName: D
NamePrefix:  
NameSuffix:  
Credential: MSW LSW
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 5663 GENDER RD
Address2:  
City: CANAL WINCHESTER
State: OH
PostalCode: 431107702
CountryCode: US
TelephoneNumber: 6143021478
FaxNumber:  
Practice Location
Address1: 1620 E BROAD ST
Address2:  
City: COLUMBUS
State: OH
PostalCode: 43203
CountryCode: US
TelephoneNumber: 6143021478
FaxNumber:  
Other Information
ProviderEnumerationDate: 04/27/2015
LastUpdateDate: 07/05/2018
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: M
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: N
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
104100000XS1450434OHY Behavioral Health & Social Service ProvidersSocial Worker 

No ID Information.


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