Provider Demographics
NPI:1104397199
Name:DEKEN, KALYSSA (LPCC)
Entity Type:Individual
Prefix:
First Name:KALYSSA
Middle Name:
Last Name:DEKEN
Suffix:
Gender:F
Credentials:LPCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:DEPT 781625 PO BOX 78000
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48278-1625
Mailing Address - Country:US
Mailing Address - Phone:614-355-8004
Mailing Address - Fax:
Practice Address - Street 1:495 E MAIN ST STE A
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43215-5349
Practice Address - Country:US
Practice Address - Phone:614-355-8055
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-12-17
Last Update Date:2021-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHC.1901696101YM0800X
OHE.2102095101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH1473276Medicaid