Provider Demographics
NPI:1265591119
Name:KRELL, CONSTANCE G (LISW)
Entity type:Individual
Prefix:MS
First Name:CONSTANCE
Middle Name:G
Last Name:KRELL
Suffix:
Gender:F
Credentials:LISW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:50 N MILLER RD
Mailing Address - Street 2:FAIRLAWN FAMILY PRACTICE
Mailing Address - City:FAIRLAWN
Mailing Address - State:OH
Mailing Address - Zip Code:44333-3702
Mailing Address - Country:US
Mailing Address - Phone:330-836-9721
Mailing Address - Fax:330-836-9627
Practice Address - Street 1:50 N MILLER RD
Practice Address - Street 2:FAIRLAWN FAMILY PRACTICE
Practice Address - City:FAIRLAWN
Practice Address - State:OH
Practice Address - Zip Code:44333-3702
Practice Address - Country:US
Practice Address - Phone:330-836-9721
Practice Address - Fax:330-836-9627
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-06
Last Update Date:2014-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHSW02842Medicare ID - Type UnspecifiedLISW