Provider Demographics
NPI:1467905075
Name:KELLY, KRISTEN GIDEL (LPCC, LICDC, CTTS)
Entity Type:Individual
Prefix:
First Name:KRISTEN
Middle Name:GIDEL
Last Name:KELLY
Suffix:
Gender:F
Credentials:LPCC, LICDC, CTTS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:384 STREAMWATER DR
Mailing Address - Street 2:
Mailing Address - City:BLACKLICK
Mailing Address - State:OH
Mailing Address - Zip Code:43004-8132
Mailing Address - Country:US
Mailing Address - Phone:419-344-9079
Mailing Address - Fax:
Practice Address - Street 1:384 STREAMWATER DR
Practice Address - Street 2:
Practice Address - City:BLACKLICK
Practice Address - State:OH
Practice Address - Zip Code:43004-8132
Practice Address - Country:US
Practice Address - Phone:419-344-9079
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-07-31
Last Update Date:2016-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHE.1110035101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH757OtherDEPARTMENT OF VETERANS AFFAIRS