Provider Demographics
NPI:1346427374
Name:STEVENSON, KELLY (LISW-S)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:STEVENSON
Suffix:
Gender:F
Credentials:LISW-S
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:
Other - Last Name:DANOLFO
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:9220 MENTOR AVE
Mailing Address - Street 2:
Mailing Address - City:MENTOR
Mailing Address - State:OH
Mailing Address - Zip Code:44060-6412
Mailing Address - Country:US
Mailing Address - Phone:404-354-9924
Mailing Address - Fax:
Practice Address - Street 1:9220 MENTOR AVE
Practice Address - Street 2:
Practice Address - City:MENTOR
Practice Address - State:OH
Practice Address - Zip Code:44060-6412
Practice Address - Country:US
Practice Address - Phone:440-354-9924
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-01-22
Last Update Date:2022-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHI08001411041C0700X
OHS0031743104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker