Provider Demographics
NPI:1932796299
Name:KEYERLEBER, KATHLEEN SUE
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:SUE
Last Name:KEYERLEBER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3937 W 160TH ST
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44111-4203
Mailing Address - Country:US
Mailing Address - Phone:216-372-2011
Mailing Address - Fax:
Practice Address - Street 1:21900 ADDINGTON BLVD
Practice Address - Street 2:
Practice Address - City:ROCKY RIVER
Practice Address - State:OH
Practice Address - Zip Code:44116-3951
Practice Address - Country:US
Practice Address - Phone:216-372-2011
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-21
Last Update Date:2020-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH2857869374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2857869Medicaid