Provider Demographics
NPI:1245588375
Name:FASIG, KEVIN (LPCC-S, LICDC)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:
Last Name:FASIG
Suffix:
Gender:M
Credentials:LPCC-S, LICDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:246 NORTHLAND DR STE 200A
Mailing Address - Street 2:
Mailing Address - City:MEDINA
Mailing Address - State:OH
Mailing Address - Zip Code:44256-3440
Mailing Address - Country:US
Mailing Address - Phone:330-725-9195
Mailing Address - Fax:330-725-9187
Practice Address - Street 1:246 NORTHLAND DR STE 200A
Practice Address - Street 2:
Practice Address - City:MEDINA
Practice Address - State:OH
Practice Address - Zip Code:44256-3440
Practice Address - Country:US
Practice Address - Phone:330-725-9195
Practice Address - Fax:330-725-9187
Is Sole Proprietor?:No
Enumeration Date:2012-08-21
Last Update Date:2020-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHLICDC.161660101YA0400X
OHLE-00019042101YP2500X
OHE.1300003-SUPV101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0181362Medicaid