Provider Demographics
NPI:1083620850
Name:ALTIC, KELLY M (MSW, LISW-S)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:M
Last Name:ALTIC
Suffix:
Gender:F
Credentials:MSW, LISW-S
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:670 MERIDIAN WAY STE 225
Mailing Address - Street 2:
Mailing Address - City:WESTERVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:43082-2304
Mailing Address - Country:US
Mailing Address - Phone:614-974-9808
Mailing Address - Fax:
Practice Address - Street 1:670 MERIDIAN WAY STE 225
Practice Address - Street 2:
Practice Address - City:WESTERVILLE
Practice Address - State:OH
Practice Address - Zip Code:43082-2304
Practice Address - Country:US
Practice Address - Phone:614-974-9808
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-31
Last Update Date:2021-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHI0070239-SUPV1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0324160Medicaid