Provider Demographics
NPI:1073934105
Name:KELLY, K. MICHELLE (LSW, LPCC)
Entity Type:Individual
Prefix:MRS
First Name:K.
Middle Name:MICHELLE
Last Name:KELLY
Suffix:
Gender:F
Credentials:LSW, LPCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2587 BACK ORRVILLE RD
Mailing Address - Street 2:
Mailing Address - City:WOOSTER
Mailing Address - State:OH
Mailing Address - Zip Code:44691-9523
Mailing Address - Country:US
Mailing Address - Phone:330-264-9579
Mailing Address - Fax:330-264-0946
Practice Address - Street 1:2587 BACK ORRVILLE RD
Practice Address - Street 2:
Practice Address - City:WOOSTER
Practice Address - State:OH
Practice Address - Zip Code:44691-9523
Practice Address - Country:US
Practice Address - Phone:330-264-9579
Practice Address - Fax:330-264-0946
Is Sole Proprietor?:No
Enumeration Date:2013-12-16
Last Update Date:2016-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHC.1300607101YP1600X
OHS.0025386104100000X
OHE.1300607101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YP1600XBehavioral Health & Social Service ProvidersCounselorPastoral
No104100000XBehavioral Health & Social Service ProvidersSocial Worker