Provider Demographics
NPI:1356853170
Name:CROSS, KELLYE AMANDA (LISW)
Entity Type:Individual
Prefix:
First Name:KELLYE
Middle Name:AMANDA
Last Name:CROSS
Suffix:
Gender:F
Credentials:LISW
Other - Prefix:
Other - First Name:KELLYE
Other - Middle Name:AMANDA
Other - Last Name:MORETTI
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:3433 AGLER RD STE 2000
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43219-3397
Mailing Address - Country:US
Mailing Address - Phone:614-600-2708
Mailing Address - Fax:614-476-6708
Practice Address - Street 1:3433 AGLER RD STE 2000
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43219-3397
Practice Address - Country:US
Practice Address - Phone:614-600-2708
Practice Address - Fax:614-476-6708
Is Sole Proprietor?:No
Enumeration Date:2017-11-02
Last Update Date:2017-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHI.17006841041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical