Provider Demographics
NPI:1669167862
Name:BYRNE, KELLY DIANE
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:DIANE
Last Name:BYRNE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:DIANE
Other - Last Name:ADAMS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2434 RICHMILLER LN UNIT F
Mailing Address - Street 2:
Mailing Address - City:BELPRE
Mailing Address - State:OH
Mailing Address - Zip Code:45714-1075
Mailing Address - Country:US
Mailing Address - Phone:740-517-7146
Mailing Address - Fax:
Practice Address - Street 1:1826 MCGILL RD
Practice Address - Street 2:
Practice Address - City:BELPRE
Practice Address - State:OH
Practice Address - Zip Code:45714-8315
Practice Address - Country:US
Practice Address - Phone:408-391-9313
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-04-05
Last Update Date:2023-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171M00000XOther Service ProvidersCase Manager/Care CoordinatorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHFPS.000024OtherSTATE OF OHIO MENTAL HEALTH AND ADDICTION SERVICES