Provider Demographics
NPI:1477047264
Name:KINGSBOROUGH, KELLY A (LPC)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:A
Last Name:KINGSBOROUGH
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:434 EASTLAND RD
Mailing Address - Street 2:
Mailing Address - City:BEREA
Mailing Address - State:OH
Mailing Address - Zip Code:44017-1217
Mailing Address - Country:US
Mailing Address - Phone:440-234-2006
Mailing Address - Fax:
Practice Address - Street 1:246 NORTHLAND DR STE 130
Practice Address - Street 2:
Practice Address - City:MEDINA
Practice Address - State:OH
Practice Address - Zip Code:44256-3440
Practice Address - Country:US
Practice Address - Phone:440-260-8300
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-06-15
Last Update Date:2018-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHC1500143101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional