Provider Demographics
NPI:1003293267
Name:BERADUCE, KEGAN D (MSW LISW)
Entity Type:Individual
Prefix:
First Name:KEGAN
Middle Name:D
Last Name:BERADUCE
Suffix:
Gender:M
Credentials:MSW LISW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3600 OLENTANGY RIVER RD # D-102
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43214-3437
Mailing Address - Country:US
Mailing Address - Phone:614-302-1478
Mailing Address - Fax:
Practice Address - Street 1:3600 OLENTANGY RIVER RD # D-102
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43214-3437
Practice Address - Country:US
Practice Address - Phone:614-302-1478
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-04-27
Last Update Date:2021-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHS1450434104100000X
OHI.18013431041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker