Provider Demographics
NPI:1649297557
Name:WADESON, KELLY L (PHD)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:L
Last Name:WADESON
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:250 METROHEALTH DR
Mailing Address - Street 2:METROHEALTH MEDICAL CENTER
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44109-1998
Mailing Address - Country:US
Mailing Address - Phone:216-778-8804
Mailing Address - Fax:216-778-5560
Practice Address - Street 1:250 METROHEALTH DR
Practice Address - Street 2:METROHEALTH MEDICAL CENTER
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44109-1998
Practice Address - Country:US
Practice Address - Phone:216-778-8804
Practice Address - Fax:216-778-5560
Is Sole Proprietor?:No
Enumeration Date:2006-07-16
Last Update Date:2007-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH6019103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH000000326700OtherANTHEM
OH2477421Medicaid
OHWACP30001Medicare ID - Type Unspecified
OH2477421Medicaid