Provider Demographics
NPI:1043736192
Name:MCCARTHY, KELLY KATHLEEN (LCDCII)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:KATHLEEN
Last Name:MCCARTHY
Suffix:
Gender:F
Credentials:LCDCII
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:KATHLEEN
Other - Last Name:GASPARRI
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LCDC II
Mailing Address - Street 1:625 CLEVELAND AVE NW
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:OH
Mailing Address - Zip Code:44702-1805
Mailing Address - Country:US
Mailing Address - Phone:330-455-0374
Mailing Address - Fax:330-453-6716
Practice Address - Street 1:1680 NAVE RD SE
Practice Address - Street 2:
Practice Address - City:MASSILLON
Practice Address - State:OH
Practice Address - Zip Code:44646
Practice Address - Country:US
Practice Address - Phone:330-830-8740
Practice Address - Fax:330-830-0912
Is Sole Proprietor?:No
Enumeration Date:2017-08-21
Last Update Date:2018-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHLCDCII121062101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)