Provider Demographics
NPI:1821158577
Name:OBERBRUNNER, KELLY M (MA,PC)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:M
Last Name:OBERBRUNNER
Suffix:
Gender:F
Credentials:MA,PC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:90 NORTHWOODS BLVD.
Mailing Address - Street 2:SUITE 9
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43235
Mailing Address - Country:US
Mailing Address - Phone:614-259-7610
Mailing Address - Fax:
Practice Address - Street 1:90 NORTHWOODS BLVD STE 9
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43235-4719
Practice Address - Country:US
Practice Address - Phone:614-259-7610
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-11
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHC8027101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional