Basic Information
| Provider Information | |||||||||
| NPI: | 1073934105 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KELLY | ||||||||
| FirstName: | K. | ||||||||
| MiddleName: | MICHELLE | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | LSW, LPCC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2587 BACK ORRVILLE RD | ||||||||
| Address2: | |||||||||
| City: | WOOSTER | ||||||||
| State: | OH | ||||||||
| PostalCode: | 446919523 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3302649579 | ||||||||
| FaxNumber: | 3302640946 | ||||||||
| Practice Location | |||||||||
| Address1: | 2587 BACK ORRVILLE RD | ||||||||
| Address2: | |||||||||
| City: | WOOSTER | ||||||||
| State: | OH | ||||||||
| PostalCode: | 446919523 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3302649579 | ||||||||
| FaxNumber: | 3302640946 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/16/2013 | ||||||||
| LastUpdateDate: | 04/05/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YP1600X | C.1300607 | OH | N | Behavioral Health & Social Service Providers | Counselor | Pastoral | 104100000X | S.0025386 | OH | N | Behavioral Health & Social Service Providers | Social Worker | 101YP2500X | E.1300607 | OH | Y | Behavioral Health & Social Service Providers | Counselor | Professional |
No ID Information.