Provider Demographics
NPI:1619314655
Name:KIERNAN, KELLIE NICOLE (LPC, AT-R)
Entity Type:Individual
Prefix:MRS
First Name:KELLIE
Middle Name:NICOLE
Last Name:KIERNAN
Suffix:
Gender:F
Credentials:LPC, AT-R
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:750 CROSS POINTE RD STE D
Mailing Address - Street 2:
Mailing Address - City:GAHANNA
Mailing Address - State:OH
Mailing Address - Zip Code:43230-6692
Mailing Address - Country:US
Mailing Address - Phone:614-568-6979
Mailing Address - Fax:937-998-1118
Practice Address - Street 1:750 CROSS POINTE RD STE D
Practice Address - Street 2:
Practice Address - City:GAHANNA
Practice Address - State:OH
Practice Address - Zip Code:43230-6692
Practice Address - Country:US
Practice Address - Phone:614-568-6979
Practice Address - Fax:937-998-1118
Is Sole Proprietor?:No
Enumeration Date:2013-05-31
Last Update Date:2020-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHC 1100330101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional