Basic Information
| Provider Information | |||||||||
| NPI: | 1881282093 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WEBER | ||||||||
| FirstName: | KELLEN | ||||||||
| MiddleName: | REID | ||||||||
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| Credential: | M.ED., LPC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 700 CHILDRENS DR | ||||||||
| Address2: | |||||||||
| City: | COLUMBUS | ||||||||
| State: | OH | ||||||||
| PostalCode: | 432052639 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6147222000 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 495 E MAIN ST | ||||||||
| Address2: | |||||||||
| City: | COLUMBUS | ||||||||
| State: | OH | ||||||||
| PostalCode: | 432155679 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6143558055 | ||||||||
| FaxNumber: | 6143558056 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/04/2021 | ||||||||
| LastUpdateDate: | 08/25/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 08/25/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | C200342 | OH | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
ID Information
| ID | Type | State | Issuer | Description | 1473276 | 05 | OH | MEDICAID |