Provider Demographics
NPI:1043723059
Name:KELLEY, KELLY ANNETTE
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:ANNETTE
Last Name:KELLEY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6460 HARRISON AVE STE 200
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45247-7958
Mailing Address - Country:US
Mailing Address - Phone:513-941-4999
Mailing Address - Fax:513-694-0168
Practice Address - Street 1:1907 11TH ST
Practice Address - Street 2:
Practice Address - City:PORTSMOUTH
Practice Address - State:OH
Practice Address - Zip Code:45662-4531
Practice Address - Country:US
Practice Address - Phone:513-941-4999
Practice Address - Fax:513-694-0168
Is Sole Proprietor?:No
Enumeration Date:2017-11-13
Last Update Date:2023-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHCDCA.140368101YA0400X
OHQMHS101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0269526Medicaid