Provider Demographics
NPI:1801270616
Name:BUSCH, KELLY (LPCC)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:BUSCH
Suffix:
Gender:F
Credentials:LPCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:877 BRANCH RD APT B4
Mailing Address - Street 2:
Mailing Address - City:MEDINA
Mailing Address - State:OH
Mailing Address - Zip Code:44256-1351
Mailing Address - Country:US
Mailing Address - Phone:440-292-5277
Mailing Address - Fax:
Practice Address - Street 1:877 BRANCH RD APT B4
Practice Address - Street 2:
Practice Address - City:MEDINA
Practice Address - State:OH
Practice Address - Zip Code:44256-1351
Practice Address - Country:US
Practice Address - Phone:440-292-5277
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-07-13
Last Update Date:2020-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHE.1700347101YM0800X, 101YP2500X
OHC.1400143101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional