Provider Demographics
NPI:1275806879
Name:VANSICKLE, KELLY A (LSW)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:A
Last Name:VANSICKLE
Suffix:
Gender:F
Credentials:LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1801 WATERMARK DR
Mailing Address - Street 2:STE 200
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43215-7088
Mailing Address - Country:US
Mailing Address - Phone:888-202-2965
Mailing Address - Fax:614-487-8769
Practice Address - Street 1:527 S HIGH ST
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43215-5602
Practice Address - Country:US
Practice Address - Phone:866-438-6508
Practice Address - Fax:614-227-9445
Is Sole Proprietor?:Yes
Enumeration Date:2012-02-14
Last Update Date:2021-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
251S00000X
OHI.1303572-SUPV1041C0700X
OHS.0901492104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No251S00000XAgenciesCommunity/Behavioral Health
No104100000XBehavioral Health & Social Service ProvidersSocial Worker