Provider Demographics
NPI:1427549328
Name:MACMULLIN, KELLY (LISW)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:MACMULLIN
Suffix:
Gender:F
Credentials:LISW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5982 RHODES RD
Mailing Address - Street 2:
Mailing Address - City:KENT
Mailing Address - State:OH
Mailing Address - Zip Code:44240-8100
Mailing Address - Country:US
Mailing Address - Phone:330-637-1347
Mailing Address - Fax:330-678-3677
Practice Address - Street 1:3922 LOVERS LN
Practice Address - Street 2:
Practice Address - City:RAVENNA
Practice Address - State:OH
Practice Address - Zip Code:44266-4200
Practice Address - Country:US
Practice Address - Phone:330-296-3555
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-05-25
Last Update Date:2021-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHI.1700661104100000X
OHI.1700661-SUPV104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker