Basic Information
| Provider Information | |||||||||
| NPI: | 1740787738 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BEACH | ||||||||
| FirstName: | KAELY | ||||||||
| MiddleName: | N | ||||||||
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| Credential: | OCPSA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 434 EASTLAND RD | ||||||||
| Address2: | |||||||||
| City: | BEREA | ||||||||
| State: | OH | ||||||||
| PostalCode: | 440171217 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4402342006 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 401 TUSCARAWAS ST W | ||||||||
| Address2: | |||||||||
| City: | CANTON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 447022042 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4402606466 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/07/2018 | ||||||||
| LastUpdateDate: | 04/07/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 172V00000X | Y | Other Service Providers | Community Health Worker |
No ID Information.