Provider Demographics
NPI:1326671785
Name:BECKETT, KYLEE (RA,CDCA)
Entity Type:Individual
Prefix:
First Name:KYLEE
Middle Name:
Last Name:BECKETT
Suffix:
Gender:F
Credentials:RA,CDCA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4645 LINCOLN AVE
Mailing Address - Street 2:
Mailing Address - City:SHADYSIDE
Mailing Address - State:OH
Mailing Address - Zip Code:43947-1242
Mailing Address - Country:US
Mailing Address - Phone:361-720-2666
Mailing Address - Fax:
Practice Address - Street 1:4645 LINCOLN AVE
Practice Address - Street 2:
Practice Address - City:SHADYSIDE
Practice Address - State:OH
Practice Address - Zip Code:43947-1242
Practice Address - Country:US
Practice Address - Phone:361-720-2666
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-02-13
Last Update Date:2020-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH161912405300000X
OH171783101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No405300000XOther Service ProvidersPrevention Professional