Provider Demographics
NPI:1720591506
Name:KOSTANDARAS, KELLY ANN (MSP)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:ANN
Last Name:KOSTANDARAS
Suffix:
Gender:F
Credentials:MSP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4665 FLEHARTY RD
Mailing Address - Street 2:
Mailing Address - City:NORTH OLMSTED
Mailing Address - State:OH
Mailing Address - Zip Code:44070-3317
Mailing Address - Country:US
Mailing Address - Phone:440-292-5304
Mailing Address - Fax:
Practice Address - Street 1:5209 DETROIT AVE
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44102-2224
Practice Address - Country:US
Practice Address - Phone:216-651-2037
Practice Address - Fax:216-651-4145
Is Sole Proprietor?:Yes
Enumeration Date:2017-11-15
Last Update Date:2017-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator