Provider Demographics
NPI:1376230284
Name:KELLEY, LISA
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:KELLEY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:834 S CASSINGHAM RD
Mailing Address - Street 2:
Mailing Address - City:BEXLEY
Mailing Address - State:OH
Mailing Address - Zip Code:43209-2435
Mailing Address - Country:US
Mailing Address - Phone:614-371-3632
Mailing Address - Fax:
Practice Address - Street 1:834 S CASSINGHAM RD
Practice Address - Street 2:
Practice Address - City:BEXLEY
Practice Address - State:OH
Practice Address - Zip Code:43209-2435
Practice Address - Country:US
Practice Address - Phone:614-371-3632
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-04-20
Last Update Date:2023-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHSP.00703103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchoolGroup - Single Specialty