Provider Demographics
NPI:1457801219
Name:KESIC, THERESA M (LSW, CDCA)
Entity Type:Individual
Prefix:
First Name:THERESA
Middle Name:M
Last Name:KESIC
Suffix:
Gender:F
Credentials:LSW, CDCA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:625 CLEVELAND AVE NW
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:OH
Mailing Address - Zip Code:44702-1805
Mailing Address - Country:US
Mailing Address - Phone:330-455-0374
Mailing Address - Fax:330-455-2101
Practice Address - Street 1:1660 NAVE RD SE
Practice Address - Street 2:
Practice Address - City:MASSILLON
Practice Address - State:OH
Practice Address - Zip Code:44646-9604
Practice Address - Country:US
Practice Address - Phone:330-837-9411
Practice Address - Fax:330-837-4603
Is Sole Proprietor?:No
Enumeration Date:2016-10-05
Last Update Date:2016-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHCDCA.110956101YA0400X
OHS.1500170104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No104100000XBehavioral Health & Social Service ProvidersSocial Worker