Provider Demographics
NPI:1851665574
Name:VACCA, KELLY A (LSW)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:A
Last Name:VACCA
Suffix:
Gender:F
Credentials:LSW
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:1801 WATERMARK DR
Mailing Address - Street 2:STE 200
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43215-7088
Mailing Address - Country:US
Mailing Address - Phone:888-202-2965
Mailing Address - Fax:614-487-8769
Practice Address - Street 1:15 N 3RD ST
Practice Address - Street 2:STE 300
Practice Address - City:NEWARK
Practice Address - State:OH
Practice Address - Zip Code:43055-5550
Practice Address - Country:US
Practice Address - Phone:800-533-9701
Practice Address - Fax:740-522-4263
Is Sole Proprietor?:No
Enumeration Date:2012-02-27
Last Update Date:2012-02-27
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
OHS.0028802104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker