Provider Demographics
NPI:1619742426
Name:EDWARDS, KELLY (CDCA)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:EDWARDS
Suffix:
Gender:F
Credentials:CDCA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:950 WOODBINE ST
Mailing Address - Street 2:
Mailing Address - City:WILLARD
Mailing Address - State:OH
Mailing Address - Zip Code:44890-1639
Mailing Address - Country:US
Mailing Address - Phone:419-964-3918
Mailing Address - Fax:
Practice Address - Street 1:5217 MONROE ST
Practice Address - Street 2:
Practice Address - City:TOLEDO
Practice Address - State:OH
Practice Address - Zip Code:43623-4601
Practice Address - Country:US
Practice Address - Phone:844-561-5433
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-11-21
Last Update Date:2025-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH171M00000X
OHCDCA.188255324500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility
No171M00000XOther Service ProvidersCase Manager/Care CoordinatorGroup - Single Specialty