Provider Demographics
NPI:1205473972
Name:CZACK, KELLY (MED)
Entity type:Individual
Prefix:MS
First Name:KELLY
Middle Name:
Last Name:CZACK
Suffix:
Gender:F
Credentials:MED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4 ANGELA DR
Mailing Address - Street 2:
Mailing Address - City:ATHENS
Mailing Address - State:OH
Mailing Address - Zip Code:45701-3655
Mailing Address - Country:US
Mailing Address - Phone:740-856-7727
Mailing Address - Fax:
Practice Address - Street 1:624 E MAIN ST
Practice Address - Street 2:
Practice Address - City:LANCASTER
Practice Address - State:OH
Practice Address - Zip Code:43130-3903
Practice Address - Country:US
Practice Address - Phone:740-678-0042
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-12-02
Last Update Date:2019-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health