Provider Demographics
NPI:1336627710
Name:COLON, KELLY
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:COLON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22897 US-20 ALT
Mailing Address - Street 2:
Mailing Address - City:ARCHBOLD
Mailing Address - State:OH
Mailing Address - Zip Code:43502
Mailing Address - Country:US
Mailing Address - Phone:419-445-1980
Mailing Address - Fax:
Practice Address - Street 1:22897 US-20 ALT
Practice Address - Street 2:
Practice Address - City:ARCHBOLD
Practice Address - State:OH
Practice Address - Zip Code:43502
Practice Address - Country:US
Practice Address - Phone:419-445-1980
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-30
Last Update Date:2018-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH0800843104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker