Provider Demographics
NPI:1952944506
Name:KELLY, CHANAVIA
Entity Type:Individual
Prefix:
First Name:CHANAVIA
Middle Name:
Last Name:KELLY
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 1:13804 REXWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:GARFIELD HEIGHTS
Mailing Address - State:OH
Mailing Address - Zip Code:44105-7010
Mailing Address - Country:US
Mailing Address - Phone:216-200-2522
Mailing Address - Fax:
Practice Address - Street 1:13804 REXWOOD AVE
Practice Address - Street 2:
Practice Address - City:GARFIELD HEIGHTS
Practice Address - State:OH
Practice Address - Zip Code:44105-7010
Practice Address - Country:US
Practice Address - Phone:216-200-2225
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-10-25
Last Update Date:2019-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor