Provider Demographics
NPI:1710214622
Name:FRILEY, KIMBERLY ANNE (MED PCC)
Entity Type:Individual
Prefix:MS
First Name:KIMBERLY
Middle Name:ANNE
Last Name:FRILEY
Suffix:
Gender:F
Credentials:MED PCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:625 CLEVELAND AVE NW
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:OH
Mailing Address - Zip Code:44702-1805
Mailing Address - Country:US
Mailing Address - Phone:304-550-3743
Mailing Address - Fax:330-453-6716
Practice Address - Street 1:1341 MARKET AVE N
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:OH
Practice Address - Zip Code:44714-2605
Practice Address - Country:US
Practice Address - Phone:330-453-8252
Practice Address - Fax:330-453-6716
Is Sole Proprietor?:No
Enumeration Date:2009-11-13
Last Update Date:2021-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHE.0500471-SUPV101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0181409Medicaid