Provider Demographics
NPI:1629754122
Name:WETMORE, KHANNAH KEZIAH (LISW)
Entity Type:Individual
Prefix:
First Name:KHANNAH
Middle Name:KEZIAH
Last Name:WETMORE
Suffix:
Gender:F
Credentials:LISW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:341 E 235TH ST
Mailing Address - Street 2:
Mailing Address - City:EUCLID
Mailing Address - State:OH
Mailing Address - Zip Code:44123-1509
Mailing Address - Country:US
Mailing Address - Phone:620-253-4179
Mailing Address - Fax:
Practice Address - Street 1:23625 COMMERCE PARK STE 100
Practice Address - Street 2:
Practice Address - City:BEACHWOOD
Practice Address - State:OH
Practice Address - Zip Code:44122-5847
Practice Address - Country:US
Practice Address - Phone:216-468-5000
Practice Address - Fax:216-831-4410
Is Sole Proprietor?:No
Enumeration Date:2023-06-27
Last Update Date:2023-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHI.2204081104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker