Provider Demographics
NPI:1609377514
Name:EDGELL, KELLY D (LCDCIII)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:D
Last Name:EDGELL
Suffix:
Gender:M
Credentials:LCDCIII
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:601 UNDERWOOD ST
Mailing Address - Street 2:
Mailing Address - City:ZANESVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:43701-3771
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:601 UNDERWOOD ST
Practice Address - Street 2:
Practice Address - City:ZANESVILLE
Practice Address - State:OH
Practice Address - Zip Code:43701-3771
Practice Address - Country:US
Practice Address - Phone:740-454-1266
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-02-26
Last Update Date:2018-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHLCDCIII.081187101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)