Provider Demographics
NPI:1255634556
Name:CASE, KELLY MARIE (PC)
Entity type:Individual
Prefix:MRS
First Name:KELLY
Middle Name:MARIE
Last Name:CASE
Suffix:
Gender:F
Credentials:PC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:270 REGENCY RIDGE DR
Mailing Address - Street 2:SUITE 202
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45459-4261
Mailing Address - Country:US
Mailing Address - Phone:937-396-7077
Mailing Address - Fax:
Practice Address - Street 1:270 REGENCY RIDGE DR
Practice Address - Street 2:SUITE 202
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45459-4261
Practice Address - Country:US
Practice Address - Phone:937-396-7077
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-12-09
Last Update Date:2010-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHC.0602166101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional