Provider Demographics
NPI:1497198741
Name:KASHA-CIALLELLA, CAROL (PCC-S, LICDC-CS)
Entity Type:Individual
Prefix:MRS
First Name:CAROL
Middle Name:
Last Name:KASHA-CIALLELLA
Suffix:
Gender:F
Credentials:PCC-S, LICDC-CS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:118 STOVER DR
Mailing Address - Street 2:
Mailing Address - City:DELAWARE
Mailing Address - State:OH
Mailing Address - Zip Code:43015-8601
Mailing Address - Country:US
Mailing Address - Phone:740-369-6811
Mailing Address - Fax:740-363-8742
Practice Address - Street 1:118 STOVER DR
Practice Address - Street 2:
Practice Address - City:DELAWARE
Practice Address - State:OH
Practice Address - Zip Code:43015-8601
Practice Address - Country:US
Practice Address - Phone:740-369-6811
Practice Address - Fax:740-363-8742
Is Sole Proprietor?:No
Enumeration Date:2013-04-16
Last Update Date:2016-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHE0003859SUPV101YA0400X, 101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2901088Medicaid